Communicable Disease Epidemiology and Control A Global Perspective

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.
2004 4:56am page i
Communicable Disease Epidemiology and Control
A Global Perspective
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page ii
This book is dedicated to Michael Colbourne (19191993), malariologist, teacher and

previously Dean at the Universities of Hong Kong and Singapore, who while at the
London School of Hygiene and Tropical Medicine gave me considerable help in its
preparation.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page iii
Communicable Disease
Epidemiology and Control
A Global Perspective
2nd Edition
ROGER WEBBER
Formerly of
London School of Hygiene and Tropical Medicine, UK
CABI Publishing
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page iv
CABI Publishing is a division of CAB International
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A catalogue record for this book is available from the British Library, London, UK.
Library of Congress Cataloging-in-Publication Data
Webber, Roger.
Communicable disease epidemiology and control: a global perspective /Roger Webber. - -2nd ed.
p. cm.
Includes index.
ISBN 0-85199-902-6 (alk. paper)
1. Communicable diseases- -Epidemiology. 2. Communicable diseases- -Prevention. I.
Title.
RA643.W37 2005
614.5- -dc22
2004006925
ISBN 0 85199 902 6
Typeset by Kolam Information Services Pvt. Ltd, Pondicherry, India

Printed and bound in the UK by Biddles Ltd, Kings Lynn
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page v
Contents
Introduction x
1 Elements of Communicable Diseases 1

1.1 What are Communicable Diseases? 1
1.2 The Agent 2
1.3 Transmission 7
1.4 Host Factors 11
1.5 The Environment 12
2 Communicable Disease Theory 21

2.1 Force of Infection 21
2.2 Epidemic Theory 22
2.3 Endemicity 28
2.4 Quantitative Dynamics 30
3 Control Principles and Methods 32

3.1 Control Principles 32
3.2 Control Methods Vaccination 34
3.3 Environmental Control Methods 40
3.4 Vector Control 52
3.5 Treatment and Mass Drug Administration 61
3.6 Other Control Methods 61
4 Control Strategy and Organization 62

4.1 Investigation of an Outbreak 62
4.2 Surveillance 66
v
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vi Contents
4.3 Control and Eradication 68

4.4 Campaigns and General Programmes 69
4.5 Control Organization 69
5 Notification and Health Regulations 73
5.1 International Health Regulations 73

5.2 National Health Regulations 74
5.3 Special Surveillance 74
5.4 Vaccination Requirements 74
6 Classification of Communicable Diseases 77

7 Water-washed Diseases 80
7.1 Scabies 80
7.2 Lice 81
7.3 Superficial Fungal Infections (Dermatophytosis) 82
7.4 Tropical Ulcers 83
7.5 Trachoma 84
7.6 Epidemic Haemorrhagic Conjunctivitis 86
7.7 Ophthalmia Neonatorum 87
7.8 Other Infections 88
8 FaecalOral Diseases 89
8.1 Gastro-enteritis 89
8.2 Cryptosporidosis 92
8.3 Cholera 92
8.4 Bacillary Dysentery (Shigellosis) 97
8.5 Giardia 98
8.6 Amoebiasis 98
8.7 Typhoid 100
8.8 Hepatitis A (HAV) 103
8.9 Hepatitis E (HEV) 104
8.10 Poliomyelitis (Polio) 105
8.11 Enterobius (Pin Worm) 107
9 Food-borne Diseases 108
9.1 Food Poisoning 108

9.2 Campylobacter Enteritis 111
9.3 The Intestinal Fluke (Fasciolopsis) 112
9.4 The Sheep Liver Fluke (Fasciola hepatica) 115
9.5 The Fish-transmitted Liver Flukes 115
9.6 The Lung Fluke 117
9.7 The Fish Tapeworm 118
9.8 The Beef and Pork Tapeworms 119
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Contents vii
9.9 Trichinosis 121

9.10 Other Infections Transmitted by Food 122
10 Diseases of Soil Contact 124
10.1 Trichuris (Whip Worm) 124

10.2 Ascaris 125
10.3 Hookworms 127
10.4 Strongyloides 130
10.5 Tetanus 132
11 Diseases of Water Contact 136
11.1 Schistosomiasis 136

11.2 Guinea Worm 142
12 Skin Infections 144
12.1 Chickenpox/Shingles (Varicella) 144

12.2 Measles 145
12.3 Rubella 149
12.4 Mumps 150
12.5 Streptococcal Skin Infections 151
12.6 Leprosy 152
13 Respiratory Diseases and Other Airborne Transmitted Infections 156
13.1 Tuberculosis 156

13.2 Acute Respiratory Infections (ARI) 164
13.3 Influenza 166
13.4 Whooping Cough (Pertussis) 167
13.5 Diphtheria 168
13.6 Meningococcal Meningitis 169
13.7 Haemophilus influenzae (Meningitis and Pneumonia) 172
13.8 Pneumococcal Disease 172
13.9 Otitis Media 175
13.10 Acute Rheumatic Fever 176
14 Diseases Transmitted Via Body Fluids 178
14.1 Yaws 178

14.2 Pinta 179
14.3 Endemic Syphilis 181
14.4 Venereal Syphilis 181
14.5 Gonorrhoea 183
14.6 Non-gonococcal Urethritis (NGU) 185
14.7 Lymphogranuloma Venereum 186
14.8 Granuloma Inguinale 187
14.9 Chancroid 187
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viii Contents
14.10 Genital Herpes 188

14.11 Human Papilloma Virus (HPV) 188
14.12 Human Immunodeficiency Virus (HIV) 189
14.13 Hepatitis B (HBV) 193
14.14 Hepatitis C (HCV) 194
14.15 Hepatitis Delta (HDV) 195
14.16 Ebola Haemorrhagic Fever 196
14.17 Marburg Haemorrhagic Fever 196
14.18 Lassa and CrimeaCongo Haemorrhagic Fevers 197
15 Insect-borne Diseases 198
15.1 Mosquito-borne Diseases 198

15.2 Arboviruses 199
15.3 Japanese Encephalitis (JE) 203
15.4 Dengue 204
15.5 Yellow Fever 206
15.6 Malaria 208
15.7 Lymphatic Filariasis 219
15.8 Onchocerciasis 228
15.9 Loiasis 234
15.10 African Trypanosomiasis (Sleeping Sickness) 234
15.11 American Trypanosomiasis (Chagas Disease) 241
15.12 Leishmaniasis 244
16 Ectoparasite Zoonoses 249
16.1 Plague 249

16.2 Typhus 254
16.3 Louse-borne Relapsing Fever 260
16.4 Tick-borne Relapsing Fever 260
16.5 Diseases Transmitted by Hard Ticks 263
16.6 Tick Typhus/Fever 265
16.7 Rocky Mountain Spotted Fever 266
16.8 Lyme Disease 266
17 Domestic and Synanthropic Zoonoses 269
17.1 Rabies 269

17.2 Hydatid Disease 272
17.3 Toxocariasis 275
17.4 Larva Migrans 275
17.5 Toxoplasmosis 276
17.6 Brucellosis 277
17.7 Anthrax 279
17.8 Leptospirosis 281
17.9 Lassa Fever 282
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Contents ix
18 New and Potential Diseases 284
18.1 The Animal Connection 284

18.2 The Pox Diseases 287
18.3 Nipah and the Lyssa Viruses 287
18.5 Bioterrorism 288
19 List of Communicable Diseases 290
Index 303
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Introduction
Since the first edition of this book, commu- rest of the world. Guinea worm has been
nicable diseases have caught the attention of cleared from most of the endemic area by
the world with the appearance of the severe simple improvements in water supply,
acute respiratory syndrome (SARS), bovine a tribute to rudimentary health measures.
spongiform encephalopathy (BSE or mad Leprosy, the disease of antiquity, due to an
cow disease) and new variant Creutzfeld active search and find programme has de-
Jakob disease (CJD), as well as the relentless creased to such a degree that it is no longer
increase in HIV infection. The vulnerability a health problem in many countries. Chagas
of the human population to these new dis- disease, the awful debilitating condition
eases and the difficulty that the medical ser- that has troubled South and Central America
vices have had in controlling them has for such a long time, has been declared
revealed the seriousness of communicable eradicated from Uruguay, Chile and Brazil,
diseases. Also, the use of anthrax as a with Venezuela and Argentina soon to
weapon and the potential use of other micro- follow. This has been by simple control of
organisms in this way has generated the fear the vector and improvement in standards of
and dread that developed when the great housing, attention to detail rather than some
plagues forged their relentless passage new invention.
across the world. But communicable dis- The appearance of new diseases and the
eases have always been with us not a ser- persistence of infections that have always
ious problem in developed countries, but been with us mean that a knowledge of com-
the main cause of death and infirmity in municable diseases is still necessary. Many
the developing world. Lower respiratory in- developed countries felt that communicable
fections are still the major cause of death, diseases were no longer a health problem,
and malaria, despite all the efforts of control, but they are as important as they have ever
causes considerable mortality every year. been. This is no more so than in the develop-
The news is not all bad though. Since ing world where the burden of communic-
the first edition was published, poliomyel- able diseases has always been a major
itis has been eradicated from Europe, the concern.
Americas and the Western Pacific, and con- While individuals fall sick and require
tinued good progress is being made in the the expertise of the medical profession, it is
x
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Introduction xi
the overall assessment of the cause of dis- parasitology are often taught as separate dis-
eases and how to control them that will most ciplines, but since they form such an inte-
rapidly solve the problem in the commu- gral part of many communicable diseases,
nity. Indeed, communicable diseases are the essentials have been included.
community problems and need to be looked The range of communicable diseases
at in this way. Epidemiology is the science occurring throughout the world is consider-
of communities, looking at many individ- able. A comprehensive list is given in Chap-
uals to try and discover common features ter 19, but only those of importance are
in them. From this analysis, the cause and covered in detail in the main part of the
characteristics of a disease can be worked book. Emphasis is placed on the developing
out. The emphasis in this book is, therefore, countries, as this is where most communic-
epidemiological. able diseases are found. It is hoped this
Learning about these diseases one by selection of diseases provides a more repre-
one is a long and complicated process that sentative perspective of the world situation
the doctor needs to undertake in order to (Table 1.1).
understand how to treat the individual. Whilst communicable diseases mainly
However, it is the method of transmission affect the developing world, new and emer-
that is the key to control and several diseases gent diseases, such as new variant CJD and
often share the same method of transmis- SARS have re-awakened the developed
sion. This allows diseases to be grouped to- countries to the importance of these infec-
gether so that knowing the characteristics of tions. This has now become a major issue, so
one means that any of the diseases in the a new chapter has been added to this second
group can probably be controlled in a simi- edition. Also, although most diseases arise
lar way. While there are always exceptions, within the same country, there is an inter-
grouping them should make it easier to learn national importance as more people travel to
about all the many diseases that afflict us, different countries and exotic diseases are
and this is one of the intentions of this book. imported. Concern has been raised that cli-
This seems to have been borne out, as the mate change due to global warming could
first edition has been used as a course book provide conditions for diseases to increase
for several teaching programmes and it is their range and affect countries where they
hoped that changes made in this second edi- have not normally been a problem, so a new
tion will make it even more suitable. section has been added to this edition.
Communicable diseases tend to behave While the emphasis of this book is on
in a similar pattern. Such generalizations diseases found in tropical and developing
determine the first chapters, which look at countries, it does seem to have found a
communicable disease theory, formulating useful place in the teaching programmes of
common principles in both epidemiology developed countries and, therefore, a few
and control. Classifying communicable dis- more diseases, more common in developed
ease can be by organism, clinical presenta- countries, have been added. A balance has
tion or system of the body attacked, but the to be achieved though between attempting
epidemiologist is interested in causation, to cover everything superficially or concen-
which is the approach taken here. trating on certain diseases in more depth,
Trying to find similarities can often be and within the constraints of trying to keep
useful, well shown by grouping respiratory this book to a manageable size, it is hoped
diseases into acute respiratory infections the right balance has been achieved.
(ARI), which has produced an important ad- Many of the examples are taken from
vancement in the control of this familiar my personal experience of working in the
problem. Every effort has, therefore, been Solomon Islands and Tanzania, with shorter
made to find common themes to make the periods in South America and various Asian
understanding and learning of communic- countries. Much of what I have learnt has
able diseases easier and as a consequence come from the large number of people who
their management. Also, entomology and have helped and worked with me in these
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page xii
xii Introduction
countries. I owe them a considerable debt for the World Health Organization (WHO) and
their wisdom and assistance, help that I by the publishers, CAB International, who
hope I pass on in the following pages. have been my main source. The Internet has
Experience is invaluable, but organiz- changed the whole way of researching for a
ing ones thoughts and developing a critical book and I am most grateful to the many
judgement comes from working in an aca- unknown writers who have contributed to
demic environment and many people in the the various sites I have used. But, the old-
London School of Hygiene and Tropical fashioned way of using books is still neces-
Medicine (LSHTM) have helped me in the sary and I wish to acknowledge the use of
various drafts of this manuscript. I wish to the library in LSHTM and, in particular,
particularly thank John Ackers, David Brad- Brian Furner and John Eyers for all their
ley, Sandy Cairncross, Michael Colbourne assistance.
(who sadly died before the first edition was Many organizations assisted me and
published), Janette Costello, Felicity Cutts, I am especially grateful to WHO for supply-
Paul Fine and Peter Smith. Andrew Tom- ing print quality copies of their many fig-
kins of the Institute of Child Health and Wil- ures. The Department for International
liam Cutting of the University of Edinburgh, Development (DFID) has been my employer
kindly read through sections on the child- in the Solomon Islands, Tanzania, and as a
hood infections. Maurice King gave me con- member of the Tropical Diseases Control
siderable help in the layout of the book and Programme at LSHTM. They have given me
encouragement to persevere with it. Sameen considerable assistance in this entire en-
Sidiqi from the Pakistan Institute of Medical deavour and I would particularly like to
Sciences reviewed the text for use in Asia thank the Health and Population Division
and wrote the section on rheumatic fever. Dr Low Cost Book Programme for a generous
Julie Cliff, who has spent most of her grant towards publishing costs of the first
working life in Africa and teaches at the edition.
University of Maputo, Mozambique, gave In these days of rising prices and com-
me much valuable advice as the manuscript mercial competition, it is becoming increas-
was getting ready for publication. But, one ingly difficult to produce books that are
person to whom I owe special thanks is affordable in developing countries. Every
Brian Southgate, who has been my mentor effort has been made to produce this volume
and friend for many years. He introduced me as cheaply as possible, without sacrificing
to many original concepts and has been a quality, but even so the copy price is higher
kindly guide to being more scientific. than I wished it to be. This is mainly to allow
In this edition, I particularly wish to production at a lower cost for developing
thank Chris Curtis, Peter Godfrey-Faussett, countries, so every copy bought is helping
Richard Hayes and David Warhurst from more copies to be made available where they
LSHTM for helping me update on material are most needed.
I could not find on the helpful websites of
Roger Webber
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 1
1
Elements of Communicable Diseases
1.1 What are Communicable Diseases? tries and non-communicable in the

developed world.
A communicable disease is an illness that is Epidemic diseases devastate whole
transmitted from a person, animal or inani- populations, as when measles ravaged Fiji,
mate source to another person either dir- killing adults as well as children. Popula-
ectly, with the assistance of a vector or by tions then have to start again from the sur-
other means. Communicable diseases cover vivors to recover their former strength.
a wider range than the person-to-person These are essentially young and growing
transmission of infectious diseases; they populations. With endemic diseases, it is
include the parasitic diseases in which a children who are particularly vulnerable,
vector is used, the zoonoses and all the so there is a high birth rate to compensate.
transmissible diseases. It is this element of With so many young people in the popula-
transmission that distinguishes these dis- tion, chronic non-communicable diseases
eases from the non-communicable. are uncommon, but as people live longer,
If diseases are communicable, then they such diseases become more frequent.
present in an epidemic or endemic form, Chronic non-communicable diseases, there-
while if non-communicable as acute or fore, are a problem of older aged populations
chronic, as follows: as seen in the Western world.
This division between the developed
Communicable: and developing world is purely artificial as
far as diseases are concerned. When the
. epidemic (e.g. measles); plague, or black death as it was known,
. endemic (e.g. malaria). spread across Europe, it caused as much dev-
astation as when communicable diseases
Non-communicable: were introduced to newly discovered nations
by Western explorers. The population started
. acute (e.g. accidents); again from the survivors as it has had to do in
. chronic (e.g. coronary heart disease). the developing countries. Just over a 100
years ago, measles was as serious a cause
All these can occur at the same time and of childhood death in large European cities
in the same place, but communicable dis- as it is in countries today without well-organ-
eases are more common in developing coun- ized vaccination programmes. A tropical
Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)
1
2 Chapter 1
environment is more favourable to many dis- probably a causative factor in gastric cancer.
eases than the cooler temperate regions, but The commonest cancer with a communic-
even here, tropical diseases like malaria were able cause is cancer of the cervix, which is
once common in Europe. There is nothing due to infection with the human papilloma
new or different about these artificially virus (Section 14.11). Prevention of this in-
divided parts of the world except for the re- fection by vaccination, now under trial,
sources that each is able to devote to the im- offers the greatest hope of reducing this im-
provement of its populations health. portant cause of female mortality.
Communicable diseases could be reduced Equally intriguing is the possibility that
to manageable proportions if sufficient re- atheroma has an infective cause or associ-
sources, both in financial and educational ation. With arteriosclerosis being largely re-
terms, could be spent on them and much of sponsible for coronary heart disease (CHD)
the reason why certain diseases (as illus- and a major killer in Western countries, the
trated in Table 1.1) are more common than possibility of preventing an infective causal
others is due to poverty. agent is attractive. Chlamydia pneumoniae
The difference between communicable has been found within atheroma lesions, but
and non-communicable diseases was quite not normal arteries, while cytomegalovirus
clear-cut. When it was an organism that was is able to infect the smooth muscle cells of
transmitted, the disease was communicable; arterial walls. The association of H. pylori
otherwise the disease was classified as non- and CHD now seems unlikely, but herpes
communicable. However, this strict bound- virus 1 could induce an endothelial cell re-
ary is becoming less well-defined as new sponse. The cause will probably be found to
suspect organisms are discovered or dis- be multi-factorial, but perhaps in the course
eases, by their very nature, suggest a commu- of time, nearly all diseases will be shown to
nicable origin. Various cancers are good have a transmissible factor in their caus-
examples; the link between hepatitis B ation. Even road accidents, for which there
virus (Section 14.13) and hepatocellular does not seem to be a necessity to look for a
cancer is well established and is now being predisposing cause as in a communicable
prevented by routine vaccination. Epstein disease, might be made more likely to
Barr virus (EBV) seems to be a pathogenic occur due to infection with toxoplasmosis
factor in Burkitts lymphoma, but there is (Section 17.5).
also a causal relationship with malaria; so The key to any communicable disease is
controlling malaria (Section 15.6) in Africa to think of it in terms of agent, transmission,
and Papua New Guinea, where this tumour host and environment. These components are
is found, could have a double benefit. The illustrated in Fig. 1.1, which will be used as a
EBV might also have a causal effect in non- framework in the description of this section.
Hodgkins lymphoma and nasopharyngeal There needs to be a causative agent, which
cancer. Kaposis sarcoma may well be trans- requires a means of transmission from one
mitted by the sexual route as shown by the host to another, but the outcome of infection
number of people with it who acquire human will be influenced by the environment in
immunodeficiency virus (HIV) infection via which the disease is transmitted.
sexual transmission, compared with those
becoming infected from blood transmission,
in which case the tumour occurs only rarely.
The trematode worms Schistosoma haema- 1.2 The Agent
tobium (Chapter 11) and Opisthorcerchis
sinensis (Section 9.5) are causative factors The agent can be an organism (virus, bac-
in bladder cancer and cholangiocarcinoma, teria, rickettsia, protozoan, helminth,
respectively. As a result, their control as fungus or arthropod), a physical or a chem-
communicable diseases will also reduce ical agent (toxin or poison). If the agent is an
cancer incidence. Helicobacter pylori, an or- organism, it needs to multiply and find a
ganism that thrives in gastric secretions, is means of transmission and survival.
Elements of Communicable Diseases 3
Table 1.1. The burden of communicable diseases in the world. Data from The World Health Report
2002, World Health Organization, Geneva.
DALYsa (000s) Mortality (000s)
Disease Total Females Total Females
Lower respiratory infections 90,748 42,846 3,871 1,856

HIV/acquired 88,429 42,973 2,866 1,338
immunodeficiency
syndrome (AIDS)
Diarrhoeal disease 62,451 30,818 2,001 966
Malaria 42,280 22,256 1,124 592
Tuberculosis 36,040 13,411 1,644 569
Measles 26,495 13,260 745 372
Pertussis 12,464 6,240 285 142
Tetanus 8,960 4,497 282 141
Meningitis 6,420 2,961 173 77
Lymphatic filariasis 5,644 1,327 0 0
Syphilis 5,400 2,416 167 70
Trachoma 3,997 2,915 0 0
Chlamydia (STI) 3,494 3,199 8 8
Gonorrhoea 3,320 1,883 2 2
Leishmaniasis 2,357 946 59 24
Hookworm 1,825 893 4 2
Upper respiratory infections 1,815 881 70 35
Schistosomiasis 1,760 678 15 5
Hepatitis B 1,684 605 81 28
Trichuriasis 1,649 800 2 1
Trypanosomiasis (African) 1,598 568 50 18
Otitis media 1,474 719 6 3
Ascariasis 1,181 577 4 2
Onchocerciasis 987 416 0 0
Hepatitis C 844 313 46 17
Japanese encephalitis 767 400 15 8
Dengue 653 366 21 11
Chagas disease 649 316 13 6
Diphtheria 185 89 5 3
Leprosy 177 79 4 2
Poliomyelitis 164 80 1 0
Total 415,911 199,728 13,594 6,298
a
DALY, disability-adjusted life year.
The DALY is a calculation of the morbidity and mortality of the particular disease averaged out over the
expected life of a person. It reflects the prevalence of the disease and the disability it produces. For example,
a common disease such as lymphatic filariasis will have a high DALY because of the large number infected
and the disability caused, although nobody dies from the disease.
exact replicas are produced, so that any nat-

1.2.1 Multiplication ural selection will act on batches or strains,
rather than on individuals. By contrast,
Two methods of multiplication occur, sexual reproduction offers great scope for
sexual and asexual reproduction, which variety, both within the cells of the single
have different advantages. In asexual repro- organism and from one organism to another.
duction, a succession of exact or almost This means that natural selection acts on
4
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof

HOST
Transmission Environment
Direct
I Age Sex
AGENT
N SOCIAL
Intermediate Susceptibility
Education
Multiplication host F Genetic Pregnancy
Resources
Asexual Sexual E
Vector Inherent defence mechanisms
C Physical Inflammatory PHYSICAL
Chapter 1
Survival Climate
T
Animal Resistance
Persistence Latency I Seasonality
Nutrition Multiple infections
V
Plant Trauma and debilitating
Effect E conditions
Virulence Toxicity Carriers Immunity

D
25.10.2004 12:34pm page 4

O Innate
Dose response Cyclical sub-clinical Acquired
S
Active
E
Passive
Fig. 1.1. Agent, transmission, host and environment.

individuals and variations of vigour and voirs are, therefore, the final host if several
adaptability occur. intermediaries are used.
There are different consequences of The relationship between the parasite
these methods of reproduction. With asex- and the host is one of continual challenge,
ual organisms, the strain of the organism is or what has been termed a biological arms
either successful or unsuccessful in invad- race. When the parasite first attacks a new
ing the host, whereas in sexual organisms, species, the host attempts to eliminate
certain individuals may succeed while it, resulting in a severe reaction. In the
others may not. In continuing its existence, course of time, adaptation can occur so that
only one organism of the asexual parasite the reaction of the host diminishes and
requires to be transmitted, whereas in the the adaptability of the parasite increases.
case of the sexual parasite, both male and The parasite is able to live in the host with
female adults must meet before reproduc- few ill effects (e.g. Trichuris trichiura),
tion can take place. Some parasites seem to forming an established population, continu-
be at a tremendous disadvantage, e.g. the ing with minimal reaction from the host.
filarial worm Wuchereria bancrofti, where The host then acts as a reservoir from
both male and female individuals go which parasites attack new hosts of the
through long migrations in the body to find same species or attempt to colonize different
an individual of the opposite sex, but des- species. Reservoirs can be humans, animals,
pite all these problems, they are one of the vectors or the inanimate environment (e.g.
most successful of all parasites. soil, water). However, it is always in the
Whether the organism reproduces sexu- parasites interest to improve its reproduct-
ally or asexually is relevant in treatment and ive capability. If a new mutation arises,
control. If a treatment is successful in des- which is beneficial to this end, then the mu-
troying an asexually reproducing organism, tation will be selected, generally to the
then it will also be successful against all the hosts disadvantage so that virulence can
other individuals, unless a mutation occurs, increase as well as decrease.
which will also confer resistance to the treat- The adaptability of parasites to their
ment for all others of that strain. In contrast, human hosts might even have advantages
sexual reproduction produces individuals for us. Ascaris, Trichuris and the hook-
of different vigour meaning that some indi- worms secrete substances to reduce the
viduals will succumb to treatment, while host immune response, which inadvertently
others will not. However, having two sexes are absorbed by the gut lining and help
can be a disadvantage for the organism in reduce allergy such as that due to hay
that methods of control can be devised to fever. Our more hygienic surroundings,
attack only one of the sexes or prevent by decreasing these parasites, may be re-
them from meeting. sponsible for the increase in allergic dis-
eases such as asthma in the developed
countries. It is a strange irony to actually
introduce these parasites to combat allergic
1.2.2 Survival
reactions.
Agents survive by finding a suitable host
within a certain period of time. They have Persistence Another mechanism used by
been able to improve their chances of find- parasites to survive is the development of
ing a new host or prolonging this period by a special stages that resist destruction in an
number of different methods. adverse environment. Examples are the
cysts of protozoa, e.g. Entamoeba histolytica
Reservoirs and parasite adaptability A reser- and the eggs of nematodes, e.g. Ascaris. Bac-
voir is a storage place for water, but serves as teria can persist in the environment by the
an appropriate term to describe a suitable development of spores as with anthrax and
place for storing agents of infection. Reser- tetanus bacilli (Fig. 1.2).
6 Chapter 1
Latency A developmental stage in the develop before changing into the infective
environment that is not infective to a new form. Ascaris, the hookworms and Strongy-
host is called latency. This allows the loides exhibit latency.
parasite time for suitable conditions to
70 70
Enteric 65
65
viruses
Shigella
60 SAFETY ZONE 60
Taenia
55 55
50 50
Temperature (C)
45 Vibrio cholerae 45
Ascaris 40
40
Salmonella
35 35
30 30
25 Entamoeba 25
histolytica
20 20
0.1 1 10 100 1000 10,000
1 day 1 week 1 month 1 year
Time (hours)
Fig. 1.2. Persistence of pathogens in excreta. The lines represent conservative upper boundaries for
pathogen death that is, estimates of the time temperature combinations required for pathogen inactivation.
Organisms can survive for long periods at low temperatures, so a composting process must be maintained at a
temperature above 438C for at least a month to effectively kill all pathogens likely to be found in human excreta.
From Feachem, R.G., Bradley, D.J., Garelick, H. and Mara D.D. (1983) Sanitation and Disease: Health Aspects
of Excreta and Wastewater Management. World Bank, Washington, DC, p. 79. Reprinted by permission of John
Wiley & Sons Ltd.
1.2.3 The effect of the agent the adult exhibiting severe manifestations
may be almost non-infectious. In the other-
If enough agents survive to infect a new host, wise harmless typhoid carrier, a bout of diar-
they will produce illness, the severity of rhoea can cause the passage of a sufficient
which is determined by its toxicity and number of organisms to initiate an epi-
virulence. demic.
Infectious agents produce a toxic reac- For each infectious agent, a minimum
tion due to the foreign proteins they consist number of organisms the infective dose is
of or produce in their respiratory or repro- required to overcome the defences of the
ductive process (e.g. malaria). Sometimes host and cause the disease. A large dose of
the organism produces very little toxicity or organisms may be required, such as with
it can be out of all proportions to the insig- Vibrio cholerae or very few, as with E. histo-
nificant primary infection (e.g. tetanus). lytica. In most infections, once this number
Some organisms produce toxins when is surpassed, the severity of the disease is
they grow in food, causing illness at a dis- the same whether a few or large number of
tance (e.g. Clostridium botulinum). Toxic organisms are introduced, while in others,
chemicals can also contaminate food (e.g. there is a correlation between dose and se-
adulterated cooking oil) producing an ill- verity of illness. Estimates of doses have
ness that has all the appearances of an epi- been attempted in cholera and typhoid
demic produced by a living organism. using healthy volunteers, but variables
Some agents have a very marked effect such as host susceptibility prevent any
on their host, while others a mild one. degree of precision. An example is food
A good example is influenza. In the so- poisoning where the severity of the illness
called Spanish flu of 1918, it is estimated is determined by the quantity of the infected
that 50 million people were killed world- food item that is consumed. On the benefi-
wide, while subsequent epidemics of influ- cial side, a low dose of organisms may pro-
enza have caused mainly mild infections, duce no symptoms of disease, but may be
with mortality only in the young or the sufficient to induce immunity. Poliomyel-
aged. As an infection progresses in a com- itis is one of the many examples.
munity, virulence can increase or decrease Infections with a low infective dose (e.g.
due to its passage through several individ- enteric viruses and E. histolytica) can spread
uals. Generally, virulence decreases, pas- by person-to-person contact. This means
sage through many experimental animals that the provision of a safe water supply or
being a method used in developing vac- sanitation will have little or no effect. At the
cines. other extreme are organisms like typhoid
and cholera, when a high infective dose (of
the order of 106 organisms/ml of water) is
required to produce the disease. Improving
1.2.4 Excreted load and infective dose water quality and the reduction of patho-
gens in the sewage will be beneficial to the
The number of organisms excreted can vary community.
considerably due to the type of infection or
the stage of the disease. In diseases such as
cholera, there may be vast numbers of organ-
isms excreted (106 ---1012 vibrios/g of faeces), 1.3 Transmission
whereas in hookworm infection, the number
of eggs may be comparatively few. In Schis- Communicable diseases fall into a number
tosoma mansoni, asymptomatic children of transmission patterns as illustrated in
excrete the largest number of eggs, whereas Fig. 1.3.
8 Chapter 1
Direct
Human
Environment Environment
Human Human Human
Fish Mollusc
Intermediate
Mollusc Mollusc host(s)
human
reservoir
Mollusc Fish
Human Human
Animal Vector
human Human Human human
reservoir reservoir
Animal Animal Arthropod Arthropod
Human Human
Vector
Animal Animal animal
reservoir Human Human reservoir
Animal Animal Arthropod Arthropod
Vectoranimal
reservoir to
vector
human reservoir Animal
Animal Insect
Insect Insect Human Human
Animal Insect
Fig. 1.3. Transmission cycles.

1.3.1 Direct occur due to the feeding of the arthropod or

as a result of its habits. The cycles of trans-
Direct transmission includes person- mission are:
to-person contact as from dirty fingers or
via food and water in the diarrhoeal . direct insect to human as in malaria;
diseases. Direct transmission also occurs . insect to animal with humans entering the
through droplet infection in the respiratory cycle as an abnormal host (e.g. bubonic
diseases. Autoinfection can occur where plague);
humans contaminate themselves directly . insect to animal including humans, from
from their external orifices. Examples are whom it is transmitted to other humans by
transmission of Enterobius from anal the same or another insect vector (e.g.
scratching or infection of skin abrasions yellow fever and East African sleeping
with bacteria from nose-picking. sickness).
(Snails, especially in descriptions of schis-

1.3.2 Human reservoir with intermediate host tosomiasis, are often called vectors, but they
do not carry the infection from one host to
The adults of schistosomiasis live in another and act only as intermediate hosts.)
humans, but for transmission to another
human, the parasite must undergo develop-
mental stages in a snail as intermediate 1.3.5 Zoonosis
host. In Opisthorchis, Paragonimus and
Diphyllobothrium, more than one kind of In the classification by transmission cycle,
intermediate host is required. diseases fall into two main groups: the dis-
eases where only humans are involved and
those in which there is an animal reservoir
1.3.3 Animal as intermediate host or reservoir or intermediate host. These are zoonoses,
which are infections that are naturally trans-
Animals can either be intermediate hosts as mitted between vertebrate animals and
with Taenia saginata and Taenia solium humans. They can be grouped according to
where cysticerci must develop in the animal the intimacy of the animal to the human
muscle before they infect humans or they being:
can be reservoirs such as in Chagas disease.
The infection is maintained in a wild rodent . domestic, animals that live in close prox-
reservoir, where the foraging dog becomes imity to man (e.g. pets and farm animals);
infected, bringing infection into the home . synanthropic, animals that live in close
of a vulnerable human. association with man, but are not invited
(e.g. rats);
. exoanthropic, animals that are not in close
1.3.4 Vector association with man (e.g. monkeys).
A vector carries the infection from one host The importance of this type of classification
to another either as part of the transmission is that it indicates the focality of the disease.
process, such as a mosquito, or it can be As domestic animals are universally distrib-
mechanical, for example, through the uted, domestic zoonotic diseases are cosmo-
housefly, which inadvertently transmits or- politan, whereas at the other extreme, in an
ganisms to the host on its feet and mouth exanthropic zoonosis, such as scrub typhus
parts. All vectors of importance are either or jungle yellow fever, it is quite possible for
insects, mosquitoes, flies, fleas, lice, etc. or humans to live in the same locality, but sep-
arachnids, ticks and mites. Infection may arately from the disease area. Humans have
10 Chapter 1
no part in the disease cycle, but come into The carrier state can either be transient or
contact with it only when they accidentally chronic.
enter the affected place (focus). The important features of carriers are as
In zoonoses, the animal is all-important follows:
in control. In some diseases, such as the beef
and pork tapeworms, good hygienic practice 1. The number of carriers may be far
and inspection of the animal carcass may be greater than the number of those who are
all that is required to interrupt transmission. sick.
At the other extreme, a disease such as 2. Carriers are not manifest so they and
yellow fever can never be eradicated from others are unaware that they can transmit
the population even if every man, woman the disease.
and child were immunized because the res- 3. As carriers are not sick, they are not re-
ervoir of disease remains in the monkey stricted and, therefore, disseminate the dis-
population. In a zoonosis, the animal reser- ease widely.
voir is of prime importance and only by 4. Chronic carriers may produce repeated
studying the ecology of the animal popula- outbreaks over a considerable period of
tion can any rational attempt be made to time.
control it.
Identification of carriers is a singularly diffi-
cult and generally unsuccessful exercise. If
1.3.6 Plants the carrier is asymptomatic, the organism is
often in such reduced numbers or excreted
Vegetable material that is eaten by the host at such infrequent intervals that routine cul-
can serve as a method of transmission. This ture techniques will not detect them. The
can either be a specific plant, such as water investigation has to be repeated many
calthrop on which the cercariae of Fascio- times and is probably only successful at spe-
lopsis buski encyst, or non-specific, such as cific instances, for example, during a minor
any salad vegetable that might be carrying diarrhoeal episode in a suspected typhoid
cysts of E. histolytica. carrier. A further difficulty is that clinically
unaffected people object to having investi-
gations performed on them, making the
coverage incomplete. Examples of diseases
1.3.7 Carriers and sub-clinical transmission
in which the carrier state is important are
typhoid, amoebiasis, poliomyelitis, menin-
Diseases in which there is an animal reser- gococcal meningitis, diphtheria and
voir, intermediate host or vector are com- hepatitis B. Cholera can produce more car-
plex and difficult to control, but even in riers than those that are sick. More on
the simplified transmission cycle of direct carriers will be found in the sections dealing
spread from human-to-human, complica- with each of these diseases.
tions occur with the carrier state. A carrier In some diseases, the carrier state
is a person who can transmit the infective appears to be prolonged or is perpetuated
agent, but is not manifesting the disease. when there are, in fact, no carriers. This
There are several types of carriers: may be due to cyclical sub-clinical transmis-
sion when infection is transmitted within a
. asymptomatic carriers who remain well family or throughout a community, without
throughout the infection; the subjects being aware of any particular
. incubating or prodromal carriers who are symptoms. One member of a family passes
infectious, but unaware that they are in on the disease to another and becomes free
the early stages of the disease; of it him/herself. It is then passed on to other
. convalescent carriers who continue to be family members and eventually back again
infectious after the clinical disease has so that it is maintained in a sub-clinical
passed. cycle. When someone who is susceptible to
the disease accidentally enters this cycle or as poliomyelitis and goitre, which are more
the organism is more widely disseminated, commonly found in females than males. Oc-
then a clinical outbreak occurs. This is a cupation can determine which sex is more
mechanism by which poliomyelitis is main- likely to be involved, such as in East Africa
tained in the community. where males, who hunt and collect honey
in tsetse fly infested forest, are more likely
to contract sleeping sickness. Social habits
may also be a determinant, such as the
1.4 Host Factors custom of the Fore people in Papua New
Guinea, where the women eat the brains
If the agent is transmitted to a new host, its of the recently dead, making kuru predom-
successful invasion and persistence will inantly a disease of women.
depend upon a number of host factors.
Pregnancy When a woman is pregnant, her

physiological mechanisms are altered and
1.4.1 Susceptibility she becomes more susceptible to infections.
Chickenpox is a severe disease in preg-
Genetic Certain diseases can only affect nancy and malaria attacks the pregnant
animals and when they are transmitted to woman as though she had little acquired
man, they are not able to establish them- immunity. The pregnant woman contract-
selves. An example is Plasmodium berghei, ing Lassa fever is more likely to die from
the rodent malaria parasite, which cannot the illness.
produce disease in man although closely
related to the human malaria parasite. How-
ever, some newly emergent diseases have
1.4.2 Inherent defence mechanisms
succeeded in crossing this genetic barrier,
such as HIV and severe acute respiratory
syndrome (SARS). Any infecting organism must be able to over-
Genetic disposition also determines come the bodys inherent defence mechan-
the hosts response to infecting organisms. isms. These can either be:
Mycobacteria are common in the environ-
ment, but only certain people develop tuber- . physical, such as the skin, mucus-
culosis or leprosy. The type of disease (e.g. secreting membranes or acidity of the
tuberculoid or lepromatous leprosy), is also stomach; or
determined by the genetic make-up. . inflammatory, the localized reaction,
which includes increased blood flow, the
attraction of phagocytes and isolation of
Age During the course of life, different dis-
the site of inoculation.
eases affect particular age groups. The child-
hood diseases of measles, chickenpox and
diphtheria are found at one end of the life-
span, with the degenerative diseases and 1.4.3 Resistance
neoplasms predominating at the other.
The persons susceptibility and defence
Sex The same advantages that parasites mechanisms may be altered by the resistance
derive from having two sexes, producing of the individual. This may be lowered by
many individuals of different vigour, also the following:
benefit humans, and it is thought that
evading parasites might be one of the main 1. Nutrition. Where the nutritional status is
reasons why mammals evolved with two decreased, the susceptibility to a disease is
sexes. However, one or other sex might increased, or the clinical illness is more
more commonly succumb to illness, such severe.
12 Chapter 1
2. Trauma and debilitating conditions. factors are subtle, diffuse and wide-ranging.
Poliomyelitis may be a mild or inapparent A few of the more important ones are men-
infection, but if associated with trauma, tioned in this section. These will be divided
such as an intramuscular injection, then into the social environment and the physical
paralytic disease can result. The appearance environment.
of shingles or fungal infections in debili-
tated people is often seen.
3. Multiple infections. The presence of one
1.5.1 The social environment
disease may make it easier for other
infecting organisms. Secondary respiratory
infections commonly occur in measles. Education Sufficient knowledge is available
Yaws has been noticed to increase and about most of the communicable diseases
spread more rapidly following an outbreak for them to be prevented, if only people
of chickenpox. were taught how. Education is a complex
process; it is not just teaching people, but
they must understand to such an extent that
1.4.4 Immunity they are able to modify their lives. This is
not a sudden process; changes made by one
generation are used as the starting point for
Experience of previous infection by a host
improvements or modifications in the
can lead to the development of immunity.
following. Change is always opposed and
This can either be cellular, conferred by
steps that seem easy to the educated may
T-lymphocyte sensitization or humoral,
be insurmountable for the uneducated.
from B-lymphocyte response. Immunity
Also, education is not just the adding of
can either be acquired or passive.
new knowledge, but the rational appraisal
of traditional beliefs and customs.
Acquired (both cellular and humoral) im-
An improvement in the level of educa-
munity follows an infection or vaccination
tion and understanding was probably the
of attenuated (live or dead) organisms. This
most important reason why endemic com-
will induce the body to develop an immune
municable diseases largely disappeared
response in a number of diseases. Immunity
from the developed world. As education
is most completely developed against the
improved, there was a demand for better
viral infections and may be permanent.
living standards. Good water and proper
With protozoal infections (e.g. malaria), it
sewage disposal were provided, personal
is only maintained by repeated attacks of
hygiene became a normal rather than an ab-
the organism.
normal practice and cleanliness was sanc-
tioned as a desirable attribute. All these
Passive (humoral only) immunity is the changes occurred before the advent of anti-
transfer of antibodies from a mother to her biotics. The decline of tuberculosis in Eng-
child via the placenta. Passive immunity is land and Wales (Fig. 13.3) is a classic
short lived, as in the protection of the young example of how the incidence of a major
infant against measles for the first 6 months communicable disease decreased as living
of life. Passive immunity can also be intro- standards rose.
duced (e.g. in rabies immune serum).
Resources and economics The lack of re-

sources leads to poverty, which reduces the
1.5 The Environment ability to combat disease. The term re-
sources relates to everything that people
The transmission cycle used by the agent to need to carry on their livelihood. Perhaps
reach the host takes place within an environ- the most important resource is land, which
ment that determines the success and is used by the family for living on
severity of the infection. Environmental and growing crops. Alternatively, this land
can be used to produce commodities that measuring the benefit of a health interven-
can be sold as part of a manufacturing pro- tion is difficult to do.
cess. As the society develops, education or A development of these methods in-
the ability to perform a service becomes a volves the concept of marginal costs, which
resource. is best illustrated using the three different
Resources are required to enact the strategies of a vaccination programme:
preventive methods or raise standards that (i) fixed units; (ii) mobile clinics; and
have come to be demanded by education. In (iii) outreach programmes. Using fixed
the simplest terms, food is required to build units (clinics and hospitals), the largest
up body processes and prevent malnutri- number of children will be reached for the
tion. But with a little extra money, a water least cost, but to obtain higher coverage it
supply can be built or a better house con- will cost more per child by this method
structed. (building more clinics) than by adding an
Resources, education and disease are outreach programme to the existing clinics.
inextricably linked. Diseases are best pre- To contact the remaining children (at the
vented by educating people to overcome margin of an outreach programme), it will
them, but resources are required by the edu- be cheaper to use mobile clinics. So each
cated to achieve this. Greater resources strategy has its value and it is more cost-
allow increased education and improved effective to use them in this stratified fash-
education leads to better utilization of re- ion. Another example of the economics of
sources. Both these factors help in reducing vaccination will be found in Section 3.2.8.
the incidence of communicable diseases.
Making the optimum use of resources
and balancing what is needed with what is Communities and movements People gather
available is the province of health econom- to form communities, constructing some
ics. The sick need treatment, but there may form of habitation in which to live. The
be several alternatives available and the type of structure they live in can play an
cheapest one producing the desired effect important role in the diseases they succumb
will be the most appropriate for the health to. In South America, the Reduviidae bugs
service of the country. The World that transmit Chagas disease live in the mud
Health Organization (WHO) essential drugs walls of houses, so replacing these with
programme has helped to limit unnecessary more permanent materials can prevent the
expenditure. Health economics involves as- disease. Conversely, if a fire is lit within the
sessing the actual needs of the community, house for cooking and heating, the smoke-
which are expressed as felt needs and trans- filled interior leads to an increase in acute
lated into demands, but financial restric- respiratory infections, one of the most
tions will limit what can be supplied. common of all health problems.
Health services will need to make choices The attraction of cities has resulted in one
between implementation of one scheme of the largest demographic changes in recent
and another, such as a mass drug adminis- times. For the majority of the population that
tration (MDA) programme or improved lived in rural areas, urban areas now have
curative services, basing their choices on become the commonest place of residence in
cost-effectiveness and costbenefit analysis. tropical countries. Slums have developed
In cost-effectiveness, programmes that yield in which the diseases of poverty thrive and
the greatest health improvement for the the imbalance of the sexes has led to an in-
available resources such as a vaccination crease in sexually transmitted infections
programme are chosen, whereas in cost (STIs). At the other extreme is the nomad con-
benefit analysis, the outputs of different pro- tinually moving from place to place, making it
jects are measured and emphasis given to difficult to provide maternal and child health
the one producing the greatest benefit per (MCH) services, with the result that children
unit of cost. Although costbenefit analysis are not vaccinated, making them vulnerable to
is the more desirable for long-term planning, many childhood infections.
14 Chapter 1
People have to move to get to their place many troubles that these unfortunate people
of work, attend school, visit the clinic or for suffer from.
many other reasons, but all such movements As with refugee health, a new speciality
incur a health risk. The woman collecting has developed around the health of travel-
water may make herself more vulnerable lers. The phenomenal increase in air travel
to contracting a diarrhoeal disease, by drink- has brought the risk of contracting a commu-
ing water from a polluted source, while the nicable disease in a foreign country to all
tsetse fly vectors of Gambiense sleeping kinds of people. Over 2000 cases of malaria
sickness favour biting people at water- are imported to England and Wales every
gathering places. The mother carrying her year, making it more important than many
baby to market with her makes it more liable of the indigenous health problems. HIV in-
to contact measles and whooping cough fection in European countries has changed
at a younger and more vulnerable age. from being predominantly in the homosex-
Fishermen, with their greater contact with ual community to an increasing problem in
water, are more likely to contract schisto- the heterosexual, mainly due to infections
somiasis. contracted overseas. Problems also travel in
Local migrations from one country to a the other direction when students from mal-
neighbouring country for trade or visiting aria-infected areas come to temperate coun-
relatives can pose a risk to the health of tries to study, losing their acquired immunity
individuals or families. In much of South- and rendering them liable to contract serious
east Asia, malaria is more intense along the malaria when they return home.
borders between countries, so that crossing
to the next country and staying for a few
days has been found to increase the chance
of contracting malaria by as much as sixfold. 1.5.2 The physical environment
Following trading routes was the way by
which classical cholera was taken to East Topography The nature of the physical sur-
Africa in the 19th century and repeated roundings can influence the diseases that
with El Tor cholera in the 20th century. are found there. In much of Asia, a complex
Schistosomiasis was carried to the Americas interaction termed forest fringe malaria de-
and Arabia along with the slaves who were scribes the greater likelihood of developing
forcibly taken to these parts of the world; a malaria at the forest margin. The man enters
continuing vengeance for the evils inflicted the forest to fell timber, often illegally, while
on them. the woman goes there to collect firewood,
Travel to another country permanently bringing them into range of mosquitoes that
to seek employment or escape from civil live within the forest cover. A similar cycle
conflict is a particularly vulnerable time for of transmission occurs with yellow fever
the individual and the family. Refugees, in as illustrated in Fig. 16.3. Destruction of
particular, need extra help, but sometimes primary forest, to be replaced by secondary
this can be misplaced and the situation growth, makes ideal conditions for the de-
made worse. During the Cambodian crisis, velopment of mite islands, which are
water containers were provided to house- important in scrub typhus (Section 16.2).
holds in refugee camps along the Thai Human activity not only destroys the
border, but these proved to be excellent natural balance of nature, but also often
breeding places for Aedes mosquitoes, with changes the landscape to make it more suit-
the result that there were large outbreaks of able for the transmission of communicable
dengue. In Tanzania, refugees were settled diseases. The growing of rice in paddy fields
in a large uninhabited forest area, which was provides suitable conditions for Culex mos-
infested with tsetse flies, so soon cases of quitoes that transmit Japanese encephalitis
sleeping sickness began to appear. Refugee and Anopheles sinensis, the vector of mal-
health has become a subject in its own right aria in much of China. The construction of
and communicable diseases are one of the dams and irrigation canals has encouraged
the proliferation of intermediate host snails breeding sites for Anopheles mosquitoes,
of schistosomiasis. However, the Simulium but excessive rain can wash out larvae and
fly that transmits onchocerciasis breeds in cause a reduction in the number of mosqui-
fast-flowing oxygenated streams that are toes. Some diseases, such as trachoma,
often destroyed when dams are built, de- favour dry arid regions.
priving them of their breeding place. All
major construction projects should, there- Wind produces local alterations to the
fore, have a health evaluation to determine weather. A major wind system is the mon-
how the health risk can be minimized. soon, which brings rainfall to the Indian
sub-continent and Southeast Asia. In West
Climate can be divided into different Africa, the hot dry Harmattan blows down
components of temperature, rainfall from the Sahara, reducing humidity and in-
(humidity) and less importantly, wind. creasing dust. It is these secondary effects on
These attributes of the climate have a rainfall and temperature that determine the
marked influence on where diseases are disease patterns.
found and the ways in which they are to be The winds are appreciated by man to
controlled. improve his living conditions in the warm
moist areas of the world and avoided in the
Temperature varies by distance from the hot dry zones. However, excess wind in hur-
equator, altitude, prevailing winds and the ricane areas or the localized tornado cause
size of land masses. A number of diseases destruction and loss of life (Fig. 1.5). Natural
are found only in the tropics, which is the disasters disrupt the normal pattern of life,
main area for communicable diseases. Tem- destroy water supplies and provide ideal
perature decreases with altitude so that mal- conditions for epidemics to occur.
aria will be found at the lower hot altitudes,
while respiratory diseases are common in Seasonality Temperature and rainfall to-
the colder hills. At the fringe of the mosqui- gether determine the best time to grow
toes range, exceptional conditions of tem- crops and the seasonal patterns of a number
perature and humidity can produce of diseases. In areas of almost constant rain,
epidemic malaria. there is very little seasonal variation, but in
Temperature not only affects the pres- the drier regions, seasonality can be quite
ence or absence of disease, but also often marked. These areas are illustrated in Fig.
regulates the extent. The malaria parasite 1.4.
has a shorter developmental cycle as the The pattern of life determined by sea-
temperature rises, thereby permitting an in- sonality can be generalized as follows:
creased rate of transmission. Many insect
vectors have a more rapid development in . Food stores are low or absent during the
the tropics, making them difficult to control. rains as it is the longest time since the
The life cycle of a number of parasites are harvest.
directly related to temperature. . During the rains, people are required to
work their hardest when they have the
Rainfall is perhaps the most essential elem- least amount of food.
ent in human livelihood. Rainfall must be . The rains bring seasonal illnesses, espe-
sufficient and regular (Fig. 1.4) allowing cially diarrhoea and malaria, which debili-
people to plant crops and ensure that they tate just when complete fitness is required.
come to fruition. An irregular rainfall can be . The time of the rains often coincides with
as disastrous as a low rainfall, leading to late pregnancy for the woman, conception
failed crops, malnutrition and a reduction having taken place during harvest. Since
of resistance to infection. all members of the family are required to
Rainfall also has a direct effect on cer- work in the fields and much of the burden
tain diseases. Moderate rainfall creates fresh of cultivating falls on the woman, the
16
Chapter 1
Fig. 1.4. The tropics rainfall and seasonality. - - - -,The tropics, Cancer to Capricorn; , developing country zone. Seasonality within the tropical region: , rainfall in
every season; , heavy seasonal rainfall; , variable seasonal rainfall; &, arid.
, revolving tropical storms (tornadoes, hurricanes, cyclones).
, earthquake areas; *, active volcanoes;
Fig. 1.5. Natural disaster zones.
18 Chapter 1
increased strain threatens her pregnancy, lutants from the many dry months, makes
while her physical reserves are stretched this a period of diarrhoeal diseases. The sea-
even further. sonality of cholera, allows a warning system
. Once harvest comes, then body weight is to be implemented and prevention initiated
restored, excess crops are stored or sold (see Section 8.6).
and some respite taken before the cycle 4. A different pattern of seasonal diseases
repeats itself. occurs with the viral infections, where
measles (see Fig. 1.7) serves as a good
This pattern leads to the following observa- example. As measles confers life-long im-
tions: munity, the only way that sufficient suscep-
tibles can accumulate for another epidemic
1. Attendance for treatment at medical to occur is by immigration or reproduction.
institutions and admission to hospital often If the birth rate is high, a critical number of
follow a cyclical pattern. This is illustrated susceptibles will soon be produced and
in Fig. 1.6 where it will be seen that annual epidemics will occur. If the birth
the reporting of ill health is least during rate is low, then the interval may be every
the dry months and increases with the 23 years.
rains. 5. Knowledge of the seasonality of a disease
2. Knowledge of the seasonality of a disease allows planned preventive services. If a
can be used in health planning, the deploy- mobile or mass vaccination campaign is
ment of manpower, the ordering of supplies, used to combat measles, then timing it in
the best time to take preventive action, etc. the few months before an expected epidemic
3. Many illnesses show a marked seasonal is the most cost-effective. In Tanzania,
pattern. Mosquitoes require water to breed, measles outbreaks often occur in the rainy
so rainfall will determine a seasonal pattern season (Fig. 1.7), a time of shortages, malnu-
for many of the vector-borne diseases. The trition and difficult communications the
massive contamination of rivers caused by worst possible time to have to do emergency
the first rains washing in accumulated pol- vaccination to contain the epidemic. Just a
1.6
Rain Rain
1.5
No. of admissions (thousands)
1.4
1.3
1.2
1.1
0.9
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Month
Fig. 1.6. Seasonality of admissions to Mbeya hospital, Tanzania, 19801983.

few months before, there was little ill health, there has been an increase in the frequency
nutritional status was high, road conditions and severity of storms in many parts of the
good and medical staff were at their slackest. world.
This would have been the best time to Increase in temperature has the poten-
ensure that every child was vaccinated. tial to expand the range of infections that
are normally constrained by temperature,
for example, malaria. This has led to specu-
1.5.3 Climate change due to global warming lation that malaria could become a problem
in the developed countries of Europe and
The increase in carbon dioxide and other North America where it occurred in former
pollutants in the atmosphere due to the times. However, this is unlikely as good pre-
burning of fossil fuels (coal, petrol, etc.) ventive measures are able to keep the dis-
has led to an increase in global temperature. ease from spreading even if the malarial
Although the temperature increase is com- mosquito re-establishes itself. A good
paratively small, it has begun to have a major example is Australia where much of the
effect on the climate, with a disruption of country lies within the tropical region,
weather systems and a raising of the sea the main malaria vector Anopheles farauti
level. This has been most marked on a (the same as Papua New Guinea and
system of currents off the west coast of Solomon Islands) is present, yet control
South America known as the El Nino south- methods have eradicated the parasite and
ern oscillation. Climatic systems are re- continued surveillance has prevented it
versed or severely disrupted, with heavy from being re-introduced.
rains and flooding when no rain is normally A more serious problem is in areas of
expected and drought conditions when highlands within tropical countries such as
there should normally be rain. Countries in East Africa and South America. At a certain
South America, Southeast Asia and Oceania altitude where the lower temperature pre-
are the most affected, but its effects are felt vents the mosquito and parasite from de-
all over the world. Even without El Nino, veloping, malaria is not found, but
500
400
No. of measles
300
200
100
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Month
Fig. 1.7. Mean monthly measles cases, 19771981, Mbeya region, Tanzania.
20 Chapter 1
evidence from Ethiopia and Kenya has likely that most of the effects will be concen-
shown that this level is already rising. Mal- trated in the poorer regions of the world,
aria is now found at higher altitudes with with an increase in vector-borne and diar-
the rate of ascent linked to the rise in tem- rhoeal diseases, malnutrition and natural
perature. There is also a greater risk of epi- disasters.
demic malaria with the wider fluctuations of
temperature that have resulted and the
number of people who have no immunity.
Other diseases transmitted by mosquitoes 1.5.4 Medical geography
like dengue and Japanese encephalitis, and
other arboviruses, such as Rift Valley fever, Features such as topography, climate and
are likely to increase. altitude are more commonly the province
Effects will be most felt at the extremes of geography than medicine, but their value
of the world, i.e. the tropics and the Arctic is appreciated and epidemiologists are
and Antarctic regions. If ocean levels rise, making more use of geographical tools to
then small island nations will be threatened help them understand the distribution and
by a reduction in land area on which to live spread of disease. The classic tool is the map
and grow their crops and salinity will in- and many examples will be found in several
trude into freshwater aquifers. Thirteen of sections of this book where maps are used.
the 20 major conurbations are at sea level A development of mapping is Geographical
and the population at risk from storm surges Information Systems (GIS) using the wealth
could rise from 45 to 90 million people. of data collected by orbiting satellites. These
Countries at greatest risk are Bangladesh, map the surface of the world at frequent
China, Egypt and the small island nations intervals so that comparisons can be made
of the Pacific, Caribbean and Indian Oceans. over time. Features known to be important
At the other extreme, a rise in temperature in disease transmission, such as the distri-
could damage the permafrost, upsetting the bution of populations or the breeding places
balance of nature and the livelihood of the of disease vectors can be identified from sat-
indigenous people who live in these parts of ellite images and predictions made without
the world. The increase in carbon dioxide having to laboriously follow-up these fea-
will result in preferential conditions for tree tures on the ground. Examples are the move-
growth and the development of forests, ment of people into the Amazon jungle
which would be beneficial in the long run, where yellow fever is endemic and detailed
but the animals that live in these lands study of a small area for mosquito-related
might not be able to adjust to the rate of features, such as rice-paddy, which can
change and become extinct. then be looked for in satellite images for
While most of the concern of increase in the whole country. GIS is at the forefront of
disease due to global warming has been ex- monitoring changes that are resulting from
pressed in the Western world, it is more global climatic change.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:50am page 21
2
Communicable Disease Theory
The previous chapter attempted to unify such as proximity (density) of populations,

communicable diseases into basic units, carriers, reservoirs, climate and seasonality,
the agent, a route of transmission to a host will have separate effects. To single these
and the way the environment influences the out and ascribe values to them will involve
outcome. Generalizations have been made considerable, and generally unnecessary,
in attempting to limit and clarify all the al- complexity. In some disease patterns, cer-
ternatives and variations that are possible. tain factors have sufficient influence that
Developing principles, not discovering ex- they require to be given values, but for the
ceptions, has been the objective. A stage is time being, it is best to consider these al-
now reached where interactions between together as a force of infection. This can be
these various elements can be suggested summarized as:
and tried. The approach can either be intui-
tive, a method used with reasonable success The force of infection
in earlier attempts at explaining disease dy- Number of infectious individuals
namics, or analytical, where the precision, Transmission rate
ease of modification and extrapolation are
considerably greater.
Therefore:
Number of newly infected individuals

2.1 Force of Infection Force of infection
Number of susceptible individuals in
In a communicable disease, the number of the population
new cases occurring in a period of time is
dependent on the number of infectious per- If the susceptible population is sufficiently
sons within a susceptible population and large to maintain a permanent pool of sus-
the degree of contact between them. Per- ceptibles (as would happen in a disease
sons, whether infectious or susceptible, where there is little or no immunity) and
and a period of time are all quantifiable the force of infection is constant, then
factors, but the degree of contact can depend newly infected individuals will continue
upon very many variables (some of which to be produced, while infectious individuals
have been covered above). The factors, remain in the population. One healthy
21
22 Chapter 2
carrier might continue to infect a large an unusual disease, a few cases could be an
number of individuals over a long period epidemic, whereas with a common disease
of time, or a brief devastating epidemic, (e.g. gastroenteritis), an epidemic occurs
with a short period of infectiousness, may when the usual rate of the disease is substan-
infect a large number of people over a short tially exceeded. Criteria can be set so that
period of time. Parasitic infections, such as when the number of cases exceeds this
hookworm, would be an example of the level the epidemic threshold is crossed.
former and measles, an example of the latter. The epidemic threshold can either be the
Of course, measles produces immunity, upper limit of cases expected at that particu-
which will alter the size of the susceptible lar time, an excess mortality, or a combin-
population. ation of both the number of cases and the
The proportion of susceptible individ- mortality.
uals can be reduced by mortality, immunity Characteristics of an epidemic (Fig. 2.1)
or emigration, or increased by birth or immi- are as follows:
gration. After a certain period of time, a suf-
ficient number of non-immune persons 1. Latent period, the time interval from ini-
would have entered the population for a tial infection until start of infectiousness.
new epidemic of the disease to occur. 2. Incubation period, the time interval from
initial infection until the onset of clinical
disease. The incubation period varies from
2.2 Epidemic Theory disease to disease and for a particular dis-
ease has a range. This range extends from a
Epidemics can occur unexpectedly, as when minimum incubation period to a maximum
a new disease enters a community, or can incubation period (see Chapter 19).
occur regularly at certain times of the year, 3. Period of communicability, the period
as in epidemics of measles. Epidemic con- during which an individual is infectious.
trasts with endemic, which means the The infectious period can start before the
continuous presence of an infection in the disease process commences (e.g. hepatitis)
community and is described by incidence or after (e.g. sleeping sickness). In some dis-
and prevalence measurements. This section eases, such as diphtheria and streptococcal
will cover epidemics and how they are infections, infectiousness starts from the
measured. date of first exposure.
Epidemic means an excess of cases in
the community from that normally Various factors modify the incubation
expected, or the appearance of a new infec- period so that if it is plotted on a time-
tion. The point at which an endemic disease based graph, it is found to rise rapidly to a
becomes epidemic depends on the usual peak and then tail off over a longer period
presence of the disease and its rate. With (Fig. 2.2). The infecting dose, the portal of
Infection Infectious
Incubation period Disease

Time
Latent period Period of communicability
Fig. 2.1. Parameters of an infection (see text for definitions).

Communicable Disease Theory 23
Infection
Minimum Time
incubation
period
Maximum incubation period
Fig. 2.2. Distribution curve of incubation times (the epidemic curve).
entry, immune response of the host and a . Common source epidemics can further be
number of other factors modify the normal divided into a point source epidemic
distribution to extend the tail of the graph. resulting from a single exposure, such as
By using a log-time scale, this skewed curve a food poisoning episode, or an extended
can be converted to a normal distribution epidemic resulting from repeated mul-
and the mean incubation period measured. tiple exposures over a period of time (e.g.
An epidemic can either be a common a contaminated well).
source epidemic or propagated source epi- . In a propagated source epidemic, the
demic (Fig. 2.3). agent is spread through serial transfer
Common source epidemics
Point source Extended source

Incidence
Incidence
Time Time
Propagated source epidemic

Incidence
Time
Fig. 2.3. Epidemic types.

24 Chapter 2
from host to host. With a disease having In a point source epidemic, the number of
a reasonably long incubation period, the cases of the disease occurring each day are
initial peaks will be separated by the plotted on a graph to produce an epidemic
median incubation periods. Chickenpox curve. The earliest cases will be those with
(varicella) can start as an epidemic in one the minimum incubation period and the last
school; then mingling children will lead of the cases are those with the maximum
to transfer to another school, leading to a incubation period if all were infected at a
series of propagated epidemics. single point in time, as illustrated in Fig. 2.4.
Three factors describe a point source
epidemic:
2.2.1 Investigation of a common source
. the epidemic curve;
epidemic
. the incubation period of the disease;
. the time of infection.
In the investigation of any outbreak of a
disease, the basic approach is to gather infor- If only two of these factors are known, then
mation on the following: the third can be deduced. From the epi-
demic curve, the median (or geometric
1. Persons: age, sex, occupation, ethnic mean) of the incubation periods is deter-
group, etc. comparing the number infected mined. If the disease is known from its clin-
with the population at risk. ical features, then the incubation period will
2. Place: country, district, town, village, also be known (Chapter 19). Therefore, by
household and relationship to geographical measuring this known incubation period
features such as roads, rivers, forests, etc. back in time from the median incubation
conveniently marked on a map. period on the curve or the minimum incuba-
3. Time: annual, monthly (seasonal), daily tion period from the beginning of the curve,
and hourly (nocturnal/diurnal). The the time of infection can be calculated. The
number of cases occurring within each source now localized to a restricted period
time-period is plotted on a graph. These of time can be more easily investigated.
aspects will be covered in greater detail If the disease is unknown, but there
later. is evidence of the time of infection (e.g.
Median or geometric
mean incubation period
Number of cases
Curve of specific disease x
Time onset of disease

Minimum
Incubation
Maximum times
Fig. 2.4. Investigation of a point source epidemic.

a particular event in time that brought all the In a new infection, everyone will be at risk
cases together or linked them by a common (e.g. with the SARS virus), but as the infec-
phenomenon), then the incubation period tion spreads, persons will become immune
can be calculated and a disease (or aetio- and are therefore no longer at risk. Where an
logical agent producing a disease) with this epidemic occurs at regular intervals (e.g.
incubation period can be suspected. This measles), only those people who have not
method was used to work out the incubation met the infection before or have not been
period for the first epidemic of Ebola haem- vaccinated will be at risk.
orrhagic fever, as there were a large number
of fatal cases that occurred in one hospital at
the same time. 2.2.2 Investigation of propagated source
In an extended source epidemic, the epidemics
time of infection can be deduced by
measuring back in time from the first case With a propagated source epidemic, phases
on the rising epidemic curve to the max- of infection occur at regular intervals. The
imum and minimum incubation periods of time-period between these phases is called
the diagnosed disease. Search within this the serial interval (Fig. 2.5). Features of the
defined period of time can elucidate the epidemic are measured in the same way as a
source. common source epidemic, while an esti-
Epidemics are suitably described by ex- mate of time of recurrence is given by the
pressing them in attack rates. In a common serial interval. After several propagated epi-
source epidemic, the overall attack rate is demics, cases remaining from the previous
used: epidemic will merge with the next so that
the regular serial pattern will be lost.
Overall attack rate Contagiousness or the probability that
Number of individuals affected during an epidemic an exposure will lead to a transmission is
Number (of susceptibles) exposed to the risk measured by:
Serial interval
Secondary Tertiary cases

Primary case cases
One minimum
incubation period
One maximum incubation period
Fig. 2.5. Investigation of a propagated source epidemic.

26 Chapter 2
Secondary attack rate

from a single case in an unlimited, wholly
Number of cases within the period of susceptible population. For example, if one
one minimum and one maximum case gave rise to two and these two to four,
incubation period (secondary cases) etc., as illustrated in Fig. 2.6, the basic repro-
from the primary case ductive rate would be 2. This is the most
Number (of susceptibles) exposed to the risk extreme situation. In reality, the epidemic
is modified by immunity or the population
An example is smallpox, which had a high limited by people having already become
secondary attack rate and was therefore very infected; therefore, such a rapid increase
contagious. Since smallpox was eradicated does not occur. If the basic reproductive
and people are no longer vaccinated, the rate is less than 1, as illustrated in Fig. 2.7,
level of immunity has waned and there is the epidemic will not take off. The import-
the fear that a very similar disease, monkey- ance of this concept is in control, whereby if
pox, could now increase and be a threat. the basic reproductive rate can be reduced
However, it has a lower secondary attack below 1, then the disease will die out.
rate; so we can rest assured that this is un- The basic reproductive rate has been
likely to happen (see also Section 18.2). used in mathematical models of disease,
particularly for malaria and filariasis.
2.2.3 Dynamics of epidemics

2.2.4 Population size
The increase in cases in an epidemic has
given rise to a measure called the basic re- As mentioned above, the continuation of an
productive rate. This measures the average epidemic is determined by the number of
number of subsequent cases of an infection susceptibles remaining in the population.
1 2 4 8 16 32
Case reproductive rate = 2
Fig. 2.6. Basic reproductive rate increasing i.e. >1. Maximal transmission: every infection produces a new
case.
4.5 3 2 1.3
Basic reproductive rate = 0.66
Fig. 2.7. Basic reproductive rate decreasing i.e. <1. Unsustained transmission: each transmission gives rise
to less than one new case and the infection dies out.
Once an individual has experienced an epi- structure and the conditions (hygiene, etc.)
sode of the disease (whether manifest or of the host population. In third world coun-
not), he or she may develop immunity tries with their high birth rates the critical
(either temporary or permanent) or die. population is less than that in developed
When a certain number of individuals have countries. Examples of the critical human
developed immunity then there are insuffi- population size are for measles 500,000 and
cient susceptibles and the infection dies out. for varicella 10,000.
This collective permanent immunity (as If the population is less than the critical
occuring in viral infections) is called the size, then regular epidemics will occur at
herd immunity. After a period of time, intervals related to the population size. An
depending on the size of the population, example is given in Fig. 12.2 of a measles
this herd immunity becomes diluted by epidemic, which occurred regularly every 3
new individuals born (or by immigration) years in a well-defined community. These
and a new epidemic can take place. This is regular epidemics can be analysed in the
called the critical population (the theoret- same way as a propagated source epidemic,
ical minimum host population size required from which it has been shown that the
to maintain an infecting agent). It depends smaller the community, the longer is the
upon the infectious agent, the demographic interval between epidemics.
28 Chapter 2
An extension of the concept of herd

immunity shows that not everyone in a
Suspected cause Cases Controls
population needs to be vaccinated to pre-
vent an epidemic. On the same principle Present a b
as calculating the critical population, the Absent c d
critical rate of vaccination coverage can
also be worked out. In other words, the
population that will need to be successfully In the example above, the relative risk of
vaccinated to reduce the population at risk contracting cholera after eating raw fish is
below the epidemic threshold. It can be
similarly shown that even if this target is 31 60
77:5:
not reached, then the epidemic will be put 38
off until a future date when the susceptible
unvaccinated children will have grown
older and therefore be able to cope with Cohort studies A cohort is a group of people
the infection better. This is illustrated in all exposed to the same aetiological agent.
Fig. 12.2. By following this group over time, the risk of
developing disease can be measured. A
modification of the technique can be used
2.2.5 Investigating food- and water-borne in outbreak investigation, particularly food
epidemics poisoning. This compares the attack rate in
the persons exposed to the factor with the
attack rate in those not exposed to the factor.
Other epidemiological techniques are useful
In a food poisoning outbreak, where various
for investigating food- and water-borne epi-
foods are suspected, then the attack rates in
demics, particularly casecontrol and
those eating and not eating the range of
cohort study methods.
foods can be compared. This is best illus-
trated by using an example as shown in
Casecontrol studies An example of the use Table 2.1. The relative risk for each food
of a casecontrol study in a cholera investi- item is calculated as above and the results
gation is given where fish were suspected to set down in a table. Most of the relative risk
contain the aetiological agent. In this com- values are about 1, but there is over four
munity, people preferred to eat fish marin- times the risk of becoming ill if you ate
ated, but uncooked. Cases were interviewed fish, so the investigator would suspect fish
as to whether they ate raw fish and com- as being the most likely cause.
pared with a similar group who had not
had the disease. The results are set out in a
two-by-two table: there was a significant
finding w2 50.47; P <0:001. 2.3 Endemicity
An endemic disease implies that there is a

Cases Controls Total constant rate of infection occurring in the
community. As new individuals are born,
Ate raw fish 31 8 39
they become infected, are cured (including
Did not eat raw 3 60 63
fish self-cure), retain the infection for life or
Total 34 68 102 become immune. Prevalence rates will
measure the level of endemicity as it applies
to the community. Incidence rates will
A reasonable estimate of the relative measure change in the level of infection
risk can be arrived at (as the incidence rates over a period of time.
are not known) from the two-by-two table, While it is useful to compare prevalence
using the odds ratio, ad/cb: from one community to another, on more
Table 2.1. Food-specific attack rates and the relative risks of eating different foods (meal eaten by 152
persons).
Ate Did not eat
Food item Sick Well Attack rate (%) Sick Well Attack rate (%) Relative risk
Rice 115 28 80.4 45 4 55.5 1.4

Potatoes 111 31 78.2 9 1 90.0 0.9
Fish 93 22 80.9 17 30 18.9 4.3
Beans 101 29 77.7 16 6 72.7 1.1
Coconut 86 22 79.6 24 20 54.5 1.5
Bananas 109 32 77.3 10 1 90.9 0.8
careful investigation, it will be found that equally to a community, then the overall
within a community, prevalence rates can decrease in disease will leave the foci to
also vary. These areas of increased preva- maintain infection. However, if the foci are
lence within a community are called foci. identified and treated, then the infectious
Two types of foci occur: source is contained (Fig. 2.8).
Incidence rates show change in the en-
. host focality, where some individuals
demicity either upwards, downwards or
have more severe infection than others,
remaining the same. A decreasing incidence
e.g. worm load in schistosomiasis;
will indicate that the disease may be dying
. geographical focality, where certain
out, especially if control measures have
localities have a higher prevalence rate
been used. Incidence rates often show a sea-
than others. Malaria exhibits geographical
sonal pattern (Fig. 1.7) and threshold levels
focality.
that take into account this seasonal variation
These concepts are important in control can be set to give early warning of the dis-
strategy. When a control method is applied ease becoming epidemic.
Fig. 2.8. The focality of endemic disease. (a) A universally homogenous prevalence rate is measured in an
area. (b) Once control measures have been implemented, foci of persistent transmission are revealed.
30 Chapter 2
2.4 Quantitative Dynamics means that the potential for infecting the
rest of the family has hardly altered. (This
Estimates of the magnitude of the infectious is a simplistic example implying that the
process, or the degree of control likely to be eggs will still be concentrated where infec-
achieved, can be calculated. As an introduction is most likely to occur.)
tion to quantitative dynamics, examples of
helminth infections are used.
2.4.2 Schistosomiasis
2.4.1 Hookworm An idealized situation is illustrated in

Fig. 2.9. Ten people with schistosomiasis
Consider a family of five people with four are all potential polluters of a body of water.
out of the five infected with hookworms, Each gram of faeces might contain 80 eggs,
producing on average some 4000 eggs/g of but if only half of them reach the water, then
faeces. Approximately 200 g of faeces are there are still 40 200 (an average stool spe-
voided by the average person each day, so cimen is 200 g) 8 103 eggs per person or
the four people are excreting 4 4000 8 104 eggs from all ten people, reaching the
200 3:2 106 eggs=day. If each of these water every day. The miracidium that
eggs results in a viable larva, then the poten- hatches from the egg needs to find a host
tial for infection would be astronomical. snail to complete its development. Snails
If the head of the household is now per- can reproduce rapidly so that one snail can
suaded to install a latrine and he encourages produce a colony in 40 days and be infective
his family to use it, then hopefully there in 60 days. The numbers of cercariae liber-
should be no further contamination of the ated from a snail are immense, but because
surroundings and infection will decrease as they need to find a human host within 24 h
the worms die off. Unfortunately, his (generally less), few are successful. The ten
youngest child does not understand how to people entering the water at the other side
use a latrine and despite being taken to it by of the picture could all become infected,
his mother, half of the stools are still de- but in reality, only a proportion are likely to
posited indiscriminately around the neigh- be so.
bourhood. This results in 100(g) 4000 When control is considered, there is
(eggs) 4 105 eggs deposited, which the choice of preventing pollution of the
Faecal pollution
Specific snails
Control
method
used
Final host
Prevent all Kill nearly Prevent water

faecal contamination all snails contact
Very difficult Difficult Most feasible
Fig. 2.9. Theoretical environmental control of schistosomiasis.

water, destroying the snails or preventing Of course, the situation is never as clear-
water contact. (There is also mass treatment cut as this, but the illustration is made to
of the population which will reduce the show that a sanitation or molluscicide pro-
total egg load, but for the present argument, gramme needs to be virtually perfect,
it will not be discussed here.) If latrines whereas prevention from water contact can
were provided and nine out of the ten provide complete protection to the individ-
people used them, there would still be ual. This is a simplified example, but a more
8 103 eggs from the tenth person going realistic situation can be simulated by the
into the water, sufficient to maintain almost use of mathematical models.
the same level of snail infections. If all the Mathematical models will not be
snails were destroyed except a few, then covered in any more detail here, but
within 60 days, the situation would return examples will be found in measles (Fig.
to what it was before. However, if any one of 12.1), malaria (Section 15.6 and Fig. 15.7)
the ten people could be prevented from and lymphatic filariasis (Fig. 15.10). They
making contact with the water, then his/ are especially useful in determining control
her freedom from infection would be strategy, which is the subject of the next few
absolute. chapters.
3
Control Principles and Methods
3.1 Control Principles ation can be used for animals as well as

humans. The former is more effective be-
Control can be directed either at the agent, cause animals can be forcibly restrained.
the route of transmission, the host or the Because it is difficult to quarantine humans,
environment. Sometimes it is necessary to it is not widely practised as a method of
use several control strategies. The general control, except where the disease is very
methods of control are summarized in infectious or the patient can be restrained
Fig. 3.1. easily (e.g. in hospital, Lassa fever).
Contacts People who might have become

3.1.1 The agent infected because of their close proximity to
a case are called contacts. They can be isol-
ated, given prophylactic treatment or kept
Destruction of the agent can be by specific
under surveillance.
treatment, using drugs that kill the agent
in vivo, or if it is outside the body, by the
Environmental health Methods of personal
use of antiseptics, sterilization, incineration
hygiene, water supplies and sanitation are
or radiation.
particularly effective against all agents
transmitted by the faecaloral route whether
by direct transmission or complex parasitic
3.1.2 Transmission cycles involving intermediate hosts.
When the agent is attempting to travel to Animals Whether they act as reservoirs
a host, it is at its most vulnerable position; or intermediate host animals can be con-
therefore, many methods of control have trolled by destruction or vaccination (e.g.
been developed to interrupt transmission. against rabies). If animals are to be eaten,
their carcasses can be inspected to make
Quarantine or isolation Keeping the agent at sure that they are free of parasitic stages.
a sufficient distance and for a sufficient The excretions or tissues of an animal can
length of time away from the host until it be infectious; so protective clothing and
dies or becomes inactive can be effective in gloves should be worn when handling
preventing transmission. Quarantine or isol- animals.
32
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am
Personal hygiene
Water supplies Physical protection
Sanitation Vaccination
Prophylaxis
Contacts Transmission
Quarantine Direct E Education

cyclical sub clinica n
Carriers and l
v
Intermediate i

host r
Plants Assistance
o
Agent Host n
Animal
m
Cooking e
n
Vector
t
Diagnosis and specific Communications
treatment
Disinfection
Destruction Vector control

Vaccination
Inspection
(Larvae) (Adults)
Larvicides Adulticides
Biological Biological
page 33
Notification and surveillance
Fig. 3.1. Control principles.
33
34 Chapter 3
Cooking Proper cooking renders plant own from natural or artificial infections
and animal produce safe for consumption, that it acquires.
although some toxins are heat-resistant. Artificial infection is given by vaccin-
Food should be prepared hygienically ation, or rather the objective is to administer
before cooking and stored properly after- the antigenic substances produced by the
wards. disease organisms in a vaccine without the
host developing the disease. Vaccine can be
given, but immunity does not always result
Vector control is one of the most highly due to poor administration, the vaccine no
developed methods of interrupting trans- longer being potent, or the host not develop-
mission because the parasite utilizes a ing an immune response. Therefore, the term
vulnerable stage for development and trans- vaccination is mostly used in this book to
port. Attack on vectors can either be on their indicate the administration of vaccine rather
larval stage by using larvicides and methods than immunization, which can be misunder-
of biological control, or while they are adults stood as immunity has been given.
with adulticides. The immune system of the full-term
newborn is capable of producing antibodies
and mobilizing cellular defenses. Bacillus
Calmette-Guerin (BCG) and polio can be
3.1.3 Host
given shortly after birth and killed antigen
vaccines are also effective from the first
The host can be protected by physical month of life. Some live vaccines like
methods (mosquito nets, clothing, housing, measles do not provide protection if given
etc.), by vaccination against specific dis- early because of circulating maternal anti-
eases or by taking regular prophylaxis. bodies.
Vaccines can be of four different kinds:
3.1.4 Environment 1. Live attenuated organisms give the body

an actual infection, inducing antibody pro-
duction. This is the best kind of vaccine as it
The environment of the host can be im-
generates maximal response from a single
proved by education, assistance (agricul-
dose and as a consequence, immunity is
tural advice, house building, subsidies,
long-lasting. The danger with live attenuated
loans, etc.), and improvement of communi-
vaccines is that the organisms could revert
cations (to market his produce, reach health
to the virulent strain. Examples are measles
facilities, attend school, etc.). In the course
and oral polio, which are attenuated virus
of time, these will be the most effective
infections, and BCG, which is an attenuated
methods of preventing continuation of the
bacterium.
transmission cycle.
2. Killed organisms are used when it is
not possible to produce a live attenuated
strain. Immunity does not develop so well
and the vaccine has to be repeated to induce
3.2 Control Methods Vaccination the body defence mechanisms to increase
their response. An example is pertussis
3.2.1 Vaccines (whooping cough).
3. Active components can be separated
The newborn baby carries antibodies trans- from organisms and vaccines made from
mitted from its mother across the placenta these organisms. Good immunity is pro-
and from early breast-feeding, protecting it duced, but they are expensive to manufac-
at a very vulnerable stage in life. The effects ture. An example is hepatitis B vaccine,
of these antibodies wear off after 6 weeks to 6 which is a recombinant DNA or plasma-
months so that the baby starts making its derived vaccine.
Control Principles and Methods 35
4. Toxoids are detoxified bacterial exo- early. Diphtheria, pertussis and tetanus are
toxins and are an important way of produ- normally combined in a triple vaccine (DTP)
cing antibodies to bacterial toxins. They do given at monthly intervals in early child-
not prevent the infection, but counteract the hood after the first month of age. If resources
dangerous effects of the toxin. Like killed permit, a booster dose should be given at 18
organisms, several doses have to be given months to 4 years of age. Adults should have
to induce a sufficient antibody response booster doses of adult vaccine (Td) every 10
and booster doses repeated from time to years.
time to maintain the level. Diphtheria and
tetanus toxoid are two vaccines in this Poliomyelitis infection is induced by three
category. different strains of virus. The oral polio vac-
cine (OPV) contains all three attenuated
strains of the virus, but the gut may not
3.2.2 Vaccine schedules be infected by three strains at the same
time and so three doses are required to
The type of vaccine and the age of risk ensure protection. In developing countries
of developing the target disease determine where wild poliovirus is circulating, a
the optimum time and schedule for adminis- first dose is given as soon after birth as
tering each vaccine. The characteristics of possible, followed by three other doses at
the principal vaccine-preventable diseases the same time as DTP. In the WHO global
(included in the Expanded Programme of eradication programme mass vaccination,
Immunization (EPI) programme in most regardless of previous vaccination, all chil-
developing countries) are as follows: dren under 5 years (two doses at an interval
of 4 weeks) are vaccinated, followed by
mopping up in areas of low coverage or
Tetanus can enter the neonate through an
where continuing transmission is identi-
infected umbilical cord, producing a high
fied. Endemic polio is now only found in
mortality. Protection is by immunizing
Africa and Southeast Asia. Inactivated
pregnant women with tetanus toxoid. This
polio vaccine (IPV) is favoured in many de-
protection is short lived and the child
veloped countries, but is more expensive
should be given tetanus toxoid early in
and produces less herd immunity. As the
infancy as the combined vaccine diphtheria,
reservoir of wild virus is being eliminated,
tetanus and pertussis (DTP). Toxoid is
IPV is the preferred vaccine as there is no
also given to adults as a course of three
risk of reversion of the vaccine to a patho-
vaccinations to prevent tetanus, or if not
genic form.
so protected, when there is a wound,
which could possibly be infected with
Haemophilus influenzae type b is an import-
Clostridium tetani. The World Health
ant cause of meningitis and pneumonia in
Organization (WHO) policy is to vaccinate
children under 6 years of age, particularly
all women of childbearing age with a
those 418 months and a vaccine given
lifetime total of five doses of tetanus
before this age gives a high degree of protec-
toxoid.
tion. The vaccine is a conjugate known as
Hib and has the advantage of inducing anti-
Whooping cough (pertussis) is a serious body response and immunological memory
disease of young children, often with in infants as well as reducing nasopharyn-
a fatal outcome in infants less than 6 months geal carriage of the organism, thereby redu-
old. Vaccination must start before this cing transmission. It is given at the same
time, preferably at 1 month or soon after, to time as DTP.
produce a sufficient level of antibodies.
Measles is one of the most important causes
Diphtheria is a dangerous disease at any of childhood death and disability in the
age, so it is preferable to start protection tropics. It reaches maximal prevalence
36 Chapter 3
by the end of the first year of life, but high-risk countries. BCG should not be
many children already would have been given to pregnant women or those with
infected by 612 months. Maternal anti- symptomatic HIV infection. However, even
bodies do not diminish sufficiently until in countries where there is a high level of
6 months for the attenuated virus to be ef- HIV and tuberculosis, BCG should be given
fective, so the optimal time for vaccination to all infants at birth, as it is unlikely that
is 9 months in developing countries. Pro- they would have developed symptoms of
longed immunity is obtained if vaccine is HIV infection by this time.
given later (at 1215 months) so this is a
preferable time in developed countries or Hepatitis B leads to chronic liver disease,
those in which there is a low prevalence. especially cirrhosis, which is a predisposing
A second measles vaccination should be cause of primary liver cell cancer. The
given at 45 years or on school entry (see prevalence of hepatitis B is as high as 8%
Section 12.2). in many parts of the world, but if the vaccine
is administered before infection, the disease
Rubella The objective of giving rubella vac- and carrier state are prevented. WHO recom-
cination is to reduce congenital rubella syn- mends that hepatitis B vaccine be included
drome (CRS), which occurs if a woman in the routine childhood vaccination sched-
becomes infected just before or in the first ule. It is most conveniently administered
20 weeks of pregnancy. If the vaccination in three doses at the same time as DTP,
programme is efficient, then a strategy to but in countries with a high carrier state,
eliminate rubella by giving a combined an additional dose at birth is recommended.
measles and rubella (MR) or measles, This will probably only be necessary for
mumps and rubella (MMR) vaccination to a comparatively short period of time be-
all children 912 months old can be started. cause once hepatitis B vaccine becomes
If the objective is to reduce CRS, then widely used, the carrier state will rapidly
all adolescent girls and women of childbear- decline. In developed countries where the
ing age should be vaccinated (see Section incidence is much lower, the vaccine
12.3). is given in adolescence or to those at risk,
but will probably be incorporated into the
Mumps An infection of the salivary glands, routine vaccination programme at some
mumps can cause orchitis and meningitis stage.
and more rarely encephalitis. Vaccination
is conveniently combined with MR vaccines Combinations and schedules Different vac-
and given at 912 months of age in develop- cines can be combined (e.g. DTP), or can be
ing countries or 1215 months in developed given together (e.g. DTP and polio). A suffi-
countries, with a second dose at 45 years or cient interval must be left between doses to
at school entry (see Section 12.4). allow time for the antibody response to take
place, 1 month normally being sufficient.
Tuberculosis The maximum age risk of tu- All these factors and the national character-
berculosis depends on the prevalence of istics of a country will determine the vaccin-
active infection in the community. Where ation schedule to be followed. A suggested
there are many open cases, even small chil- regime is as follows:
dren are at risk, but in a society where most
cases are in older people and individuals do
Before birth Tetanus toxoid to all women of
not contact many others until they start
childbearing age with at least
work in young adulthood, the period of two doses in the first
greatest risk is adolescence. In developing pregnancy and one in the
countries, vaccination is given at birth, second.
whereas in developed countries, BCG is Birth BCG. OPV in endemic areas
given when the child starts school or select- and hepatitis B vaccine in
ively to risk groups such as immigrants from areas of high prevalence
12 months DTP plus OPV plus hepatitis B 4. A primary course need never be repeated,
plus Hib even if the booster dose is long delayed.
23 months DTP plus OPV plus hepatitis B 5. An interrupted course can be resumed
plus Hib whenever feasible without starting from the
36 months DTP plus OPV plus hepatitis B
beginning again.
plus Hib
915 months MMR (see Sections 12.2, 12.3
6. If the interval between doses ends up
and 12.4); OPV if not given at as being longer than planned, the immuno-
birth logical effect will not be reduced. The
45 years or MMR only disadvantage of long drawn out sched-
school entry ules is that the individual is not rapidly
protected.
DTP and OPV can be given even if the child

has a mild illness. Measles vaccine can also 3.2.4 The cold chain
be given if the child is having a mild illness
as it does not have any effect for several
The cold chain is a descriptive term for the
days, by which time the minor illness
whole sequence of links that must be main-
would have been cured. Vaccination should
tained in transporting the vaccine in a viable
always be given to the malnourished child,
condition from the manufacturer to the
who is at particular risk from infection. Pro-
person to be vaccinated. Vaccines will only
tective response is good except in cases of
survive when they are maintained at the
severe kwashiorkor. (Further information
correct temperature. There are certain limits
can be found on individual vaccines under
when the vaccine can be allowed to depart
the various diseases.)
from the optimal temperature, but the range
and time are very short and vaccines rapidly
lose their potency. To vaccinate with non-
3.2.3 Operational factors potent vaccine is not only a waste of time
and money, but also brings discredit to the
In planning vaccination programmes, cul- vaccination programme.
tural, logistic and other operational factors Some vaccines are stored at freezing
largely determine the coverage. Some of temperature (poliomyelitis, BCG and
these are: measles), while others are at the standard
refrigerator temperature of 488C (DTP
1. The strongest motivation to attend MCH and tetanus). If stored at the wrong tempera-
clinics is immediately after the child has ture, the vaccine will be destroyed. The two
been born; the shorter the interval between elements of the cold chain are speed of
birth and vaccination, the more likely they transport and maintenance of a steady tem-
are to be brought by their mothers. perature; hence the fastest means of getting a
2. A range of ages, days and combinations vaccine from one place to another is used.
should be available so that the time of A temperature-sensitive strip that changes
attendance is always the right time for vac- colour if the batch becomes too warm during
cination. If a mother is told to bring her the period of transport accompanies most
child back at a set time or at a particular vaccines. The viability of the vaccine can
age of the child, then she probably will not then be checked and the problem link in
bother. the cold chain detected.
3. Admission to hospital is an ideal oppor- Cold boxes are very well insulated con-
tunity to check whether the vaccination tainers lined with freezer packs in which
schedule is up to date. Measles vaccination vaccines can be transported or stored for
is particularly important as many children up to 7 days. They are valuable for mobile
contract serious measles when admitted to vaccination teams, but for the individual
hospital for another complaint. vaccinator, a hand-held vacuum flask will
38 Chapter 3
store vaccines for 12 days, depending on economics of static and mobile vaccination
the outside temperature. clinics, see Section 1.5.1.
Certain vaccines, such as measles and Mobile clinics are easier to organize
BCG, are sensitive to light and need to be where only one dose of vaccine is required
protected while they are being diluted, (e.g. measles) and have a special place in
stored and administered to a person. Special mass campaigns.
dark glass syringes can be obtained, but
covering with a cloth is just as efficient.
Many potent vaccines are destroyed by 3.2.6 Seasonality and vaccination campaigns
being drawn up into syringes that are still
warm from the sterilizing process, a sad end Many infections follow a seasonal pattern
to a long cold chain. with sufficient regularity that peaks of
incidence can be forecast. If the pattern is
known, the epidemic can be prevented by
3.2.5 Mobile and static clinics carrying out mass vaccination before it is
expected (see Fig. 1.7).
Vaccination can be from static and/or
mobile clinics. Their various advantages
and disadvantages are given in the following 3.2.7 Ring vaccination
table:
If an epidemic is spreading, it can be con-
tained by vaccinating everyone in a ring
Static Mobile
around the site of the epidemic. Villages
should be chosen where cases have not
Coverage Limited to 10 km Large areas
radius yet been reported and an attempt made to
Availability Always Occasional vaccinate as many people as possible. If the
Transport Not required Required ring is too close to the epidemic, then the
Costs High capital, low Moderate disease might have already affected some
recurrent costs capital, high people outside the defensive ring and then
recurrent costs another will need to be started even further
Vaccine Often erratic Good away.
supplies
A static clinic responsible for providing 3.2.8 Economies of vaccination

primary care services (including delivery)
for both the mother and the child is the most Vaccination coverage is often poor because
effective. A child stands a greater chance of of constraints put on staff by the cost of
receiving all its vaccines from a static health vaccines. Vaccines should be supplied in
unit. However, as distance from the clinic small dose quantities so that a vial can be
increases, the probability of a mother bring- opened even if there is only one child to
ing her child to the clinic decreases for every be vaccinated. Spare vaccine can often be
kilometer to be walked. Coverage is best used up on other children attending the
closest to the clinic and decreases further health centre for other reasons. The cost of
away, with often large gaps between clinics vaccination is not just the price of the actual
as shown in Fig. 3.2. It is in the inadequately vial of vaccine, but includes the whole cold
covered areas between the static clinics that chain and the salary of the vaccinator. To
an epidemic is likely to occur. Outreach ser- have a vaccinator sitting around not vaccin-
vices or mobile clinics then become valuable ating because there are not enough children
in vaccinating the in-between areas. For the to warrant opening a vial is a false economy.
Fig. 3.2. Unequal vaccination coverage from static clinics. , vaccinated child; , non-vaccinated child;
Hosp., hospital; H.C., health centre; Disp., dispensary.
Proportional costs have been calculated as where AR is the attack rate (discussed in
follows: Section 2.2.1). The VE indicates the max-
imum achievable level, but poor vaccination
technique or storage can reduce this. Also,
Capital 1215% Transport 20%
the more people who are vaccinated, the
Salaries 45% Vaccine 5%
Training 23% Others 1216%
greater the number of apparent vaccine fail-
ures. If the above equation is rewritten to
express the percentage of cases vaccinated
3.2.9 Vaccine efficacy (PCV) in terms of the percentage of the popu-
lation vaccinated (PPV) and VE, then:
Vaccine efficacy (VE) is calculated by:
(AR in unvaccinated AR in vaccinated) PPV (PPV VE)
VE 100% PCV
AR in unvaccinated 1 (PPV VE)
40 Chapter 3
By knowing two of these variables, the third 3.3 Environmental Control Methods
can be calculated. Figure 3.3 shows three
curves generated from the equation, each Many diseases result from contamination of
for a different VE. These curves predict the the environment by faecal matter with trans-
theoretical proportion of cases with a vac- mission by the direct route (e.g. by fingers),
cine history. For example, if a measles epi- or via food and water. The mechanisms are
demic is observed in a population with schematically illustrated in Fig. 3.4. The
homogeneous measles exposure where various control methods available are as
90% of the individuals are vaccinated follows:
(PPV90%) with a 90% effective vaccine
(VE90%), the expected percentage of . personal and domestic hygiene;
measles cases with a history of being vaccin- . proper preparation, cooking and storage
ated would be 47% (PCV47%: Example A). of food;
However, if only 50% were vaccinated, then . use of water supplies;
9% of the cases would have been found to be . proper disposal of excreta and waste;
vaccinated (Example B). This is not to say . miscellaneous methods including meat
that there is anything wrong with the vaccin- inspection and hygiene.
ation programme, but explains why there
may appear to be an unexpected number of Classifying the water- and sanitation-related
vaccinated population amongst the cases. diseases into well-defined categories allows
Fig. 3.3. Percentage of cases vaccinated (PCV) per percentage of population vaccinated (PPV), for three
values of vaccine efficacy (VE). Reproduced by permission from Weekly Epidemiological Record 7, 20
February 1981. World Health Organization, Geneva.
rational control methods to be applied and 3 diseases are reduced by rigorous

(Table 3.1). The potential impact of control hand-washing after defecation and before
methods is seen in Table 3.2. eating.
Personal hygiene is closely related to
the availability of water in sufficient quan-
3.3.1 Personal hygiene tity. Water quality is of less importance.
Washing is improved by using warm water
Personal hygiene is the understanding by and soap. Soap reduces surface tension and
the individuals of how infections can be emulsifies oils, allowing bacteria to be more
transmitted to them or others by unclean easily removed. However, large quantities of
habits, and using appropriate methods to water can still be effective in the absence of
avoid them. Infection can be avoided by pre- soap.
venting bad habits (e.g. promiscuous defeca-
tion) or introducing good habits (e.g. hand-
washing before eating). Infections that can 3.3.2 Protection of foods
be reduced by personal hygiene are shown
in Table 3.3. Food-transmitted infections can spread
Category 1 diseases are reduced by either through contamination or by a
washing of the body and clothing with specific intermediate host. Flies indirectly
water, which is best heated and with the contaminate food. Protection of the food we
addition of soap if available. Categories 2 eat can be by the following:
Contaminated or
Faecaloral infected food and
auto-infection water
person to person
Development
in soil before
oral infection
Land-based Contaminating
intermediate host insect
Biting
insect
Insect
Penetrating Urine breeding
skin
Faeces
Water-based
Penetrating intermediate Contaminated
skin host water
Fig. 3.4. Routes of transmission of the water- and sanitation-related diseases.

42 Chapter 3
Table 3.1. A classification of water- and excreta-related diseases.
Category Characteristics Examples Transmission Control measures
1. Water- Diseases of poor Skin diseases, eye Person-to-person Personal hygiene

washed hygiene diseases, louse- (and Increase water
disease borne typhus autoinfection) quantity
2. Faecaloral (a) Low infective Enterobius, Person-to-person Personal hygiene
diseases dose amoebiasis, (and Increase water
enteric viruses autoinfection) quantity
(b) High infective Diarrhoeal diseases, Contamination of Excreta disposal
dose. Able to cholera, typhoid, food or water Cook food
multiply hepatitis A Improve water
outside host quality
3. Soil-mediated (a) Development Ascaris, hookworm, Larvae penetrate Personal hygiene
diseases in soil Strongyloides skin or swallowed Excreta disposal
(helminths)
(b) Development Taenia spp. Cysts in meat Meat inspection
in animal Cook food
(cow or pig)
intermediate
host
4. Water-based Helminths
diseases requiring
intermediate
hosts
(a) Copepods Guinea worm Ingested in water Improve water
quality
(b) Snails only Schistosomiasis Penetrates skin Reduce water
contact
(c) Two Fasciolopsis, Eating uncooked Excreta disposal
intermediate Opisthorchis, specific foods Cook food
hosts Paragonimus,
Diphyllobothrium
5. Water- and (a) Breeding in Malaria, filariasis, Mosquitoes Drain breeding sites
excreta- water or arboviruses Maintain water
related insect sewage supplies and
vectors sanitation
(b) Breeding or Onchocerciasis, Simulium Water supply at site
biting near trypanosomiasis Tsetse fly of use
water
(c) Breeding in Diarrhoeal diseases Housefly Excreta disposal
excreta
Modified from Bradley, D.J. (1978) In: Feachem, R.G. et al. (eds) Water, Wastes and Health in Hot Climates. Reproduced by
permission of John Wiley & Sons Ltd, Chichester.
. inspection of raw produce; . preventing contamination of cooked

. packaging and avoiding contamination; foods;
. suitable storage conditions and time- . eating cooked foods immediately.
limits;
. washing and correct preparation; Infections that can be reduced by the proper
. adequate and even cooking; protection of food are shown in Table 3.4.
Table 3.2. The potential impact of environmental control methods (compare with Table 3.1).
Personal Cooking Water

Disease category hygiene of foods supplies Sanitation Miscellaneous
1. Water-washed diseases
2. Faecaloral diseases
3. Soil-mediated diseases Meat inspection
4. Water-based diseases Reduce water contact
5. Water- and excreta- Protection from insects
related insect vectors
, Very effective; , moderately effective; , effective; , not effective; , can be either effective or not effective.
Table 3.3. Infections that can be reduced by personal hygiene.
Category Infection
1 Skin sepsis and ulcers

1 Conjunctivitis
1 Trachoma
1 Scabies
1 Yaws
1 Leprosy
1 Tinea
1 Louse-borne fevers
1 Flea-borne infections (including plague)
2 Enteric viruses (including hepatitis A and polio)
2 Enterobius
2 Amoebiasis
2 Trichuris
2 Giardia
2 Shigella
2 Typhoid
2 Other Salmonellae
2 Campylobacter
2 Non-specific diarrhoeal diseases
2 Cholera
2 Leptospirosis
3a Ascaris
Category 2 infections contaminate food off the intermediate stages and procedures,
before or after cooking. Flies are often in- such as roasting on a spit or cooking meat
volved. Even if contamination has occurred, under done, do not provide high enough
correct storage and the disposal of cooked temperatures inside the meat. Meat inspec-
foods after a limited time can prevent suffi- tion can be effective in Taenia infection (3b).
cient multiplication of bacteria to reach an
infective dose.
Categories 3b and 4c (Table 3.4) require 3.3.3 Water supplies
specific intermediate hosts in their transmis-
sion, so their destruction or proper cooking is Contaminated water can be the vehicle
an effective means of control. Cooking needs of transmission of a number of disease-
to be at a sufficiently high temperature to kill producing organisms. Water is also important
44 Chapter 3
in diseases of poor hygiene as a medium for water-borne etc. However, water supplies
intermediate hosts and as a breeding place need to be maintained and when they break
for vectors of disease. down, the disease can be expected to return.
The infections and possible improve- In rural water supplies where chlorine
ments that may occur as a result of installing treatment of the water is costly, difficult
a water supply are shown in Table 3.5. to maintain or inappropriate, then a differ-
ent standard to that in large centralized sup-
The provision of water There are four aspects plies may be acceptable. This should not be
of water supply, which can help to control considered unsatisfactory as the provision
disease transmission: of a properly constructed water supply is
an improvement on what was used before.
. improve water quantity; Also quality is closely related to quantity. By
. improve water quality; providing a greater volume of water at a
. reduce water contact by bringing water more accessible site, quality will usually be
to site of use; improved.
. prevent spillage by proper maintenance of Health aspects are the concern of the
supplies and drainage. medical worker, whereas the villager looks
upon water as a basic necessity. His, or
It will be noticed how this is the normal rather her (as women are nearly always the
process in the supply of water. The first carriers of water), major concerns will be
objective is to provide water in sufficient quite different. These are the following:
quantity, which is followed by improving
its quality and finally a piped system is con- . availability of water at a more convenient
structed. If this is the pattern followed, then place (preferably in the village);
similarly it can be anticipated that the first . a continuous and reliable supply;
group of diseases to be reduced will be the . additional water for crops and domestic
water-washed and faecaloral, then the animals.
Table 3.4. Reduction of infection by food protection.
Category Infection Type of food Possible reduction
2 Enteric viruses (including hepatitis All

A and polio)
2 Hymenolepis All
2 Amoebiasis All
2 Trichuris All
2 Giardia All
2 Shigella All, especially dairy produce
2 Typhoid All, especially dairy produce
2 Salmonellae All, especially dairy produce
2 Campylobacter All, especially dairy produce
2 Non-specific diarrhoeal diseases All, plus fly contamination
2 Cholera Marine animals, salad
2 Leptospirosis Rat-contaminated foods
2 Brucellosis Milk produce
3a Ascaris All
3b Taenia Cow or pig meat
4b Trichinella Pig
4c Fasciolopsis Salad
4c Opisthorchis Fish (fresh water)
4c Paragonimus Crustacea (fresh water)
4c Diphyllobothrium Fish (fresh water)
Refer to footnote of Table 3.2 for the description of +++, ++ and +.

Table 3.5. Expected improvements when installing a water supply.
Category Infection Water improvement required Possible reduction (%)
1 Skin sepsis and ulcers Increase water quantity 50

1 Conjunctivitis Increase water quantity 70
1 Trachoma Increase water quantity 60
1 Scabies Increase water quantity 80
1 Yaws Increase water quantity 70
1 Leprosy Increase water quantity 50
1 Tinea Increase water quantity 50
1 Louse-borne fevers Increase water quantity 40
1 Flea-borne diseases (including Increase water quantity 40
plague)
2 Enteric viruses (including Increase water quantity 10?
hepatitis A and polio)
2 Enterobius Increase water quantity 20
2 Hymenolepis Increase water quantity 20
2 Amoebiasis Increase water quantity 50
2 Trichuris Increase water quantity 20
2 Giardia Increase water quantity 30
2 Shigella Improve water quality 50
2 Typhoid Improve water quality 80
2 Other Salmonellae Improve water quality 50
2 Campylobacter Improve water quality 50
2 Non-specific diarrhoeal diseases Improve water quality 50
2 Cholera Improve water quality 90
2 Leptospirosis Improve water quality 80
3a Ascaris Increase water quantity 40
3a Hydatid Increase water quantity 40
3a Toxocara Increase water quantity 40
3a Toxoplasmosis Increase water quantity 40
4a Guinea worm Reduce water contact 100
4b Schistosomiasis
9 Reduce water contact 60
5a Malaria = Water piped to site of use and 10
5a Filariasis ; maintenance of water 10
5a Arboviruses supplies 10?
5b Onchocerciasis Water piped to site of use 20?
5b Gambian trypanosomiasis 80
From Bradley, D.J. (1978) In: Feachem, R.G. et al. (eds) Water, Wastes and Health in Hot Climates. Reproduced by
permission of John Wiley & Sons. Ltd, Chichester.
It is a combination of these health and social munity should be served, when they
factors that needs to be used in deciding should receive their supply and the level of
the appropriateness and benefits of water availability. There are many alternative
supplies. strategies that may be, or inadvertently
will be, used. They might include the
Economic and planning criteria Everybody following:
wants the best possible water supply they
can get, but resources are limited so it . priority of an area on health grounds;
will be many years before everyone has . priority to an area of water scarcity;
the supply they desire. Decisions have . encouragement of development to an area
to be made as to which sections of the com- of high potential;
46 Chapter 3
. priority to communities that can contrib- is 650 mm, then 10 5 650 0:8 26,000
ute in money and labour; l/year or 71 l/day, on average.
. first come, first served; The demand for water will be deter-
. political favouritism. mined by the availability, the number
of people and the use to which it is
Other alternatives in the nature of the put. Availability is the most crucial factor
supply can also be considered: as water that has to be carried some distance
will be used much more sparingly than
. supplying a large number of people with when there is a tap inside the house. Aver-
the simplest of supplies; age figures taken from a number of studies
. restricting supplies to certain demonstra- are as follows:
tion areas with a high standard;
. start with the most available natural water
sources; Rural supply 20 l/person/day
. plan a major project, such as a dam, Standpipe 40 l/person/day
followed by extension of supply in subse- Single tap in the home 80 l/person/day
quent years. Multiple taps with bath,
W.C., etc. 200300 l/person/day
This will depend on how much the country,
region, district or village is prepared to
At least 50% extra capacity is allowed for
pay for the price of water. Savings can be
future growth of the community and expan-
made by the following: (i) economies of
sion of the supply. A water source is chosen
scale; (ii) standardizing the equipment; and
where the expected demand on the supply
(iii) self-help labour.
will never be exceeded, even in the driest
The initial water master plan is best
time of the year. If this is not possible, then
formulated by skilled engineers, but its exe-
some form of storage will be required. Water
cution can be by a purpose-trained techni-
use during the night is far less than during
cian, utilizing community effort. The plan
the day, so a poor supply can be boosted by
needs to take account of health, engineering,
providing a storage tank that fills at night. In
political and community demands.
areas of wide seasonal variation, more ex-
tensive storage facilities may be required,
Water capacity and use In selecting a suit- such as a dam, to save the rainfall in the
able source, the amount of water it produces few wet months.
and its regularity need to be known. If a
spring or stream does not flow all the year Choice of water supply Choosing a water
round, then it is not suitable unless a dam is source will depend upon the following:
also built. Measurements of water flow
should be made at the end of the dry season . proximity to user;
and the people asked if the source has ever . reliability;
dried up. A temporary dam can be con- . quantity of water;
structed and the rate of filling a measured . quality of water;
bucket estimates the flow. Wells can be . technical feasibility;
mechanically pumped out and the fall . resources available;
noted for a given flow of water. Rainwater . social desirability or taboo;
catchment is derived from the simple for- . maintenance.
mula:
The alternative choices are illustrated in
1 mm of rainfall on 1 m2 of the roof in plan
Figs 3.5 and 3.6. Rainwater naturally seeps
will give 0.8 l of water.
through the earth until it finds an impervi-
As an example, if the roof plan area is ous layer (such as clay) on which it collects.
10 m 5 m and the average annual rainfall When this impervious layer comes to the
Fig. 3.5. Sources of water.
48 Chapter 3
Fig. 3.6. Water catchment and the fresh water lens of coral islands.
surface, water runs out of the ground as a ent, but poor quality water. Other sources
spring. It can also form the bed of a river or in should be used if possible, but if there is no
an enclosed area, a lake. This groundwater alternative, then some form of water treat-
can be tapped by a shallow well. At a much ment, such as filtration and storage, should
deeper level, a second impervious layer can be incorporated. A constant spring that
trap a large quantity of water. A deep well or never dries up is a very suitable source, as
bore hole is required to reach this source of it is comparatively free from contamination
water. Island populations (Fig. 3.6) have and can normally be led to an outlet without
particular problems in obtaining water and requiring pumping. Maintenance costs will,
are generally left with only two alternatives. therefore, be low, so greater capital expend-
Provided they have suitable roofing material iture can be allowed for protecting the
(e.g. corrugated iron), rainwater can be col- spring and piping its water to the village.
lected and stored in a tank. The other alter- Rainwater catchment is an under-
native is to sink a well to tap the freshwater utilized source of pure water, either as a
lens. Due to a fortunate quality of coral rock, main method or as subsidiary (for drinking
it acts like a large sponge, holding fresh water). So much good water runs to waste off
water that has percolated through, floating large expanses of roof that have already been
on the denser sea water. Provided the well is paid for in the construction of the building.
sunk just far enough and not pumped out too This water can be tapped for good use. With
hard, freshwater can be obtained. The differ- the additional cost of guttering and a tank, a
ent water sources are summarized in Table family can have a good, safe source of water
3.6. inside or very close to their house. Storage
Wells are often a good supply, as long as tanks can either be close to the roof or large
contamination can be prevented and have concrete structures built underground.
the advantage that they can be sited close Their main danger is that if water is allowed
to houses. This can be achieved by sealing to collect in poorly maintained gutters or
them and having a pump fitted, but this will uncovered tanks, then mosquitoes can
require maintenance. Deep wells and bore breed there.
holes need special equipment for their con- The ideal is to find a source that has
struction and complex pumps to lift water both constant quantity and good quality,
from these depths. They are mainly applic- but where the latter is not available, then it
able in areas of severe water shortage such as can be improved by simple methods, such as
deserts. Lakes and rivers provide conveni- the three-pot system (Fig. 3.7).
Table 3.6. Sources of water, their advantages and disadvantages.
Spring Shallow well Bore hole River Lake Catchment
Proximity Distant Near Intermediate Near Near Near

Reliability Good Variable Good Unreliable Good Unreliable
Quantity Good Moderate Good Variable Good Poor
Quality Good Moderate Good Poor Poor Good
Technology Easy Moderate Difficult Easya Easya Moderate
Cost Low Moderate High Lowa Lowa Moderate to high
Community High Moderate Moderate Low Low Moderate
preference
Maintenance Low Moderate High Low Low Moderate
a
These assessments are for taking water by hand from the river or lake. If a pump and supply system are used, then the
technology is difficult and the cost high.
50 Chapter 3
Only the top clear water that has

been standing all night is poured
off for drinking
Drinking water (clean the pot

before refilling)
The first large pot is cleaned out

and filled with freshwater. This is
left to settle until the next day
Fig. 3.7. The three-pot system a simple means of improving water quality.
3.3.4 Sanitation
supply, but nobody wants to change his or
her defecation practice. This is quite simple
With food and water supplies, the emphasis to explain in that substances taken into
is on the prevention of contamination, but the body can be understood as a direct
with sanitation, it is reducing the source of cause of illness, whereas excreting some-
the contamination. Social habits concerned thing from the body cannot. Defecation is a
with excreta disposal are often strongly held necessary, but private business and is not
and unless these are approached in a sens- a matter for discussion. There are also social
ible manner, any new system will fail. Sani- reasons that are set by religious, racial
tation is not just the provision of latrines, or cultural practice. These may dictate
but a complex and inter-related subject in- where and where not to defecate, will prob-
volving people, water supplies and all other ably separate the sexes and define particular
aspects of environmental health. anal-cleansing practices. With all these
patterns and customs that have been taught
Health factors As shown in Table 3.1, the since childhood, any change becomes a
main impact of sanitation is on groups 2, long and difficult process. If a family can
3a, 4c and 5c. The installation of sanitation see the benefits of a latrine, then they
may produce a reduction in the infections will install and look after it; the health
shown in Table 3.7. authority can then assist in technical speci-
fications and subsidize costs. Any attempt
The provision of sanitation When providing to impose systems or even build them
sanitation, there is a sharp contrast with free of charge will cause resentment or
water supplies. Everybody wants a water non-use.
Like water, sanitation has to be paid that the former is outside the house, while
for, but here costs are even less accepted by the latter carries excreta from within
the population. People are only prepared to the house. The cost of this convenience is
pay for the minimum possible in getting rid typically ten times that of a pit latrine.
of their excreta. Only in urban areas will it In choosing the most appropriate ex-
be considered necessary to pay for the re- creta disposal system, the emphasis should
moval of excrement; in rural areas, there is be on simplicity. Only when a simpler
sufficient space. A subsidizing scheme then method becomes outmoded because of
becomes the main way in which sanitation rising standards and expectations will a
can be improved. For instance, in pit latrine more sophisticated system become appro-
construction, villagers will need to dig their priate. A simple incremental process, as
own hole, but might be sold a bag of cement illustrated in Fig. 3.8, can be planned.
at a reduced price or be provided with a The first stage is to bury excreta, which
squatting slab free of charge. will lead on to using a pit latrine. If pit
Cost is related to convenience, which latrines are already accepted by the commu-
is why people are prepared to pay for nity, then demonstrating the advantages of
improved systems, their willingness to pay improved pit latrines will be the next step.
usually having nothing to do with health. The type of facility will also be determined
A good pit latrine can be as effective in dis- by the availability of water. As mentioned in
ease control as a conventional water-carried Section 3.3.3, the provision of water should
sewage system, the only difference being precede any sanitation programme as
Table 3.7. The expected improvements from the installation of sanitation.
Possible
Category Infection Through reduced contamination of reduction
1 Trachoma The environment; flies (group 5c)

2 Enteric viruses (including hepatitis A) Vegetables
2 Hymenolepis Food and water
2 Amoebiasis Vegetables
2 Trichuris Food and water
2 Giardia Food and water
2 Shigella Food and water
2 Typhoid Food and water
2 Other Salmonellae Food and water
2 Campylobacter Food and water
2 Non-specific diarrhoeal diseases Food and water
2 Cholera Food and water
3a Ascaris Soil
3a Hookworm Soil
3a Strongyloides Soil
3b Taenia Soil
4b Schistosomiasis Water
4c Fasciolopsis Water
4c Opisthorchis Water
4c Paragonimus Water
4c Diphyllobothrium Water
5 Housefly-transmitted diseases The environment; flies a
5 Filariasis Water and Culex quinquefasciatus
breeding
a
Sanitation, if not properly built or maintained, can be as responsible for increasing the fly nuisance as well as decreasing it.
Refer to footnote of Table 3.2 for the description of +++, ++, + and .
52 Chapter 3
personal hygiene can only be taught if there practice and poses considerable threat of
is water at hand to wash with. The quantity infection. The easiest solution is to lead it
and proximity of this water will then deter- into a soakaway, but precautions similar to a
mine the type of sanitary system that can latrine need to be taken.
be used. In the second part of Fig. 3.8, the
incremental progression of a water-utilizing
sanitary system is shown. A pourflush 3.4 Vector Control
latrine can be installed where water is
obtained from a village standpipe, but Parasites are transmitted from one host to
with a septic tank or sewerage, a water- another by vectors, often utilizing the stage
flushing system requires in-house water in the vector to undergo multiplication or
connections. development. In some parasites (e.g. mal-
aria) the vector is the definitive host,
Siting and contamination The unit must be whereas in others such as Wuchereria ban-
sited so that it does not contaminate the crofti, it is the intermediate host. Whichever
environment in such a way as to threaten part the vector plays, it is a vital one for the
the health of others. With a pit latrine, bac- parasite and it cannot continue if the vector
terial pollution can travel downwards for is destroyed or reduced to sufficiently low
a distance of up to 2 m. If the contamination numbers. The time of changing from one
reaches the water table, it will flow horizon- host to another is a precarious time for the
tally for up to 10 m. This means that any parasite and considerable loss may occur.
latrine should be sited at least this distance Malaria gametocyte development must coin-
away from a water supply, such as a well. cide with a mosquito taking a blood meal
The latrine should also be placed downhill and both male and female gametocytes are
to the well, although excessive pumping required for fertilization and maturation
will draw water into the well from all direc- to take place in the insects stomach.
tions, including possibly from a latrine. If W. bancrofti suffers considerable parasite
a latrine is built less than 10 m from a river loss during the vector stage. The vector,
or stream, it can pollute it, as the water table therefore, does not have to be completely
will be flowing towards the stream. Latrines destroyed, but must be kept at levels too
in this situation can be potent sources of low for transmission to take place. So vector
pollution if the river is used for drinking control means vector reduction and not
water. Pollution of the soil is a complex vector eradication.
subject and the rough rule of 10 m distance
between a latrine and source of drinking
water is given as a guide. Contamination is
3.4.1 Mosquito control
dependent upon the following:
. the velocity of groundwater flow (should The various ways in which mosquitoes can
be less than 10 m in 10 days); be controlled are as follows:
. the composition of the soil (not fissured,
e.g. as in limestone). . adulticides;
. repellents;
Expert advice should be obtained before . personal protection;
embarking on a latrine programme. . larvicides;
In a sealed system such as a septic tank . biological control;
or an aquaprivy, contamination of the soil . environmental modification.
will not take place unless there is a crack in
the structure. However, the effluent is These are all illustrated in Fig. 3.9.
highly charged with pathogens and must be
disposed of properly. Running it into a Adulticides Killing the adult mosquito can
storm drain, as often happens, is a bad either be done while it is flying using a
Surface Hole and Simple pit Improved pit or Composting
defecation bury latrine latrine latrine
DRY
SYSTEM

Pourflush Pourflush to
latrine soakaway Flush toilet to Flush toilet connected to
septic tank sewerage system
WET
SYSTEM
page 53
}
53
Fig. 3.8. Types of excreta disposal systems incremental sanitation.
54 Chapter 3
Residual
insecticides
Knock-down insecticide
Repellents
Personal
protection
Larvicides
Eggs
Pupa Larva
Biological control Environmental modification
Fig. 3.9. Mosquito control methods.
knock-down spray or when it is resting with fecting aircraft. Knock-down sprays com-
a residual insecticide. Knock-down insecti- monly contain pyrethrum, derived from
cides will kill adult mosquitoes at the time a species of chrysanthemum grown in high-
of application only, whereas residual in- land areas of East Africa. They can be
secticides continue to have a lethal effect dispersed in aerosols, smoke generators
for a considerable period of time. (fogging) or ultra-low volume (ULV) aerial
sprays.
KNOCK-DOWN INSECTICIDES are used to con-
trol epidemics of vector-transmitted disease RESIDUAL INSECTICIDES Residual spraying is
where an explosive increase in the number the main method for control of mosquito-
of flying adults is responsible. They have transmitted disease because the insecticide
been used in malaria epidemics, but have continues to remain active for 6 months or
perhaps their greatest value in dengue and more. By careful organization, repeated ap-
the control of arbovirus infections. They are plications made at regular intervals can
used as space sprays (aerosols) in the house, maintain a continuing killing effect. Ideally
for mosquito survey counts and for disin- they should be sprayed just before the start
of the main transmission season, especially allowed back into the houses. This takes a
in areas where malaria is seasonal. considerable amount of organization with
Residual insecticides act on the resting a strict schedule of notification, followed
mosquito. Mosquitoes need to rest after they by spraying. The supervisor answers any
have taken a blood meal and generally questions, ensures that the work is done
choose the nearest place, which is the wall and arranges logistic support. If residual
of the victims house. If the wall has been spraying is not adequately explained to
sprayed with residual insecticide, then people, then organizational resistance will
the mosquito will absorb a lethal dose develop. The target is to spray every dwell-
through its legs while it is resting. The ing house whether permanently or tempor-
insecticide can either be sprayed as an emul- arily occupied.
sion or wettable powder, as few of the in-
secticides commonly used go into solution Deterrents and repellents can be either
with a cheap and easily obtainable medium smokes or applications to the body in the
such as water. Emulsions are best on non- form of creams and solutions. They do not
absorbent surfaces, while wettable powders kill the insect, but deter it from biting.
are suitable for mud, leaf or other poor qual- Mosquito coils or heated pads have a
ity walls. The wettable medium (generally combined deterrent and repellent action.
water) soaks into the wall and leaves the They are made with small quantities of
powder on the surface. Some of the insecti- pyrethroids in a slow burning base, but
cide is taken into the porous surface, but this other insecticides can be added to enhance
gradually comes out, maintaining a steady the activity. Used in a still atmosphere,
concentration. Once residual insecticide they can be most effective. If they do not
has been sprayed on a wall, then it must prevent all the bites, they reduce the
not be washed or painted. number, which is important in filariasis
Residual insecticide sprayed on a sur- transmission. They reduce the probability
face depends upon a number of factors: of being bitten by an infective mosquito
carrying any disease.
. the proportion of active insecticide in the The most commonly used repellent is
preparation; diethyltoluamide (DEET), which can be
. the amount of insecticide mixed with the applied to the person, clothing, tents and
fluid medium; mosquito nets. The solutions can either
. mixing, before and during application; be dissolved in methylated spirit or emulsi-
. the distance from the surface that is fied with water and applied to the surface.
sprayed; It is not absorbed by synthetic fabrics and
. the speed of application. a cotton or wool base is essential if it is
to remain for some time. Four weeks of
These are all specified for a particular activity is given if continuously exposed,
insecticide and sprayers must be trained to but if the garments (such as a shawl or leg
ensure that the right concentration is bands) are kept in a polythene bag, then
delivered. A measured area of plaster can repellent action can continue for 3
be scraped and the insecticide content 6 months. Precaution should be taken
analysed. while applying DEET to the skin as some
Residual spraying is carried out by a individuals are sensitive, while neuro-
team of sprayers with manually operated logical toxicity can be produced in children.
spray apparatus covering a village at a time. Natural repellents made from eucalyptus
Houses are emptied and pets and domestic oil are preferable for application to the
animals restrained at a suitable place some person.
distance away (as they are sensitive to in-
secticides). Any insects, beetles and lizards Mosquito nets and personal protection Perso-
that are killed should be swept up and dis- nal protection is a valuable precaution in
posed of before the domestic animals are reducing the number of mosquito bites.
56 Chapter 3
Clothing that covers the arms and legs every year) as this decreases the effective-
especially if combined with a repellent can ness of the insecticide.
protect an individual most effectively. With Some people suffer from nasal conges-
the appearance of widespread insecticide tion when sleeping under a net that has
resistance, greater reliance must now be recently been treated with deltamethrin or
placed on personal protection. lambda-cyhalothrin and it is probably better
The use of mosquito nets is a well-tried to put it to one side for the first 2 days if
method of personal protection. Mosquito either of these insecticides has been used.
nets are fitted to the bed and the edges Otherwise they are perfectly safe and no
tucked under the mattress. A knock-down long-term effects have been recorded.
spray applied prior to retiring will prevent One of the problems of treating mos-
any mosquitoes entering the net when the quito nets is that they need to be retreated
occupant goes to bed. Young children at annual or 6-monthly intervals, so a recent
should be placed under nets before it gets innovation has been long-lasting insecti-
dark. If the custom is to sleep on a mat on the cidal nets (LLIN) where the insecticide is
floor rather than a bed, then mosquito nets impregnated into the fibre of the net before
can still be used. The sale of subsidized it is woven. Such nets are effective for
mosquito nets can be an effective method 4 years or more and, therefore, are being
of malaria control, if they are subsequently actively promoted for malaria control.
treated with an insecticide. A less satisfactory alternative is to
Mosquito nets are treated with screen the whole house, but this is expen-
synthetic pyrethroids, such as permethrin, sive and a torn area will destroy the whole
deltamethrin, lambda-cyhalothrin or alpha- effect. Air conditioning, by providing
cypermethrin. They deter mosquitoes from a sealed room, generally prevents mosqui-
entering should the net be torn or kill it if it toes from entering. Even so, it is preferable
touches the net. Nylon nets are better than to use a knock-down spray in the evening
cotton because they absorb less solution and to prevent any mosquitoes that may have
are stronger, but this has to be offset by their entered. The cost of these methods is con-
greater cost. Additional advantages of siderably higher than using treated
treated nets are that they provide some pro- mosquito nets.
tection to other people sleeping in the same
room. They also kill fleas, lice, bed bugs and Larvicides Substances that block the
cockroaches and even if rolled up will still breathing apparatus of mosquito larvae and
provide some protection. A modification of destroy the surface tension (so they sink to
this method is to treat curtains that are used the bottom) or poison them are known as
to cover doors, windows or any opening. larvicides. Kerosene spread on water covers
These methods are used in community mal- the siphon of the larvae so that it dies from
aria control programmes. asphyxiation. High-spreading oils have
Nets are treated by soaking them in a been developed, which inactivate the force
solution of the insecticide when new or of surface tension that larvae use to float on
after they have been washed. The amount the surface. Insecticides sprayed on collec-
of insecticide is 200 mg/m2 permethrin, tions of water will kill larvae as well as many
25 mg/m2 deltamethrin or 10 mg/m2 other organisms (including fish), are expen-
lambda-cyhalothrin, calculated by measur- sive and generally objected to by the public
ing the area of the net. Some treated net and hence are rarely used as larvicides.
programmes are using standard sized nets, Such preparations as temephos (Abate),
all of which are made of the same material, with its very low toxicity, are a notable ex-
to avoid having to measure each one, but a ception.
rough approximation can be made by Larvicides are not efficient methods of
weighing each net. Once nets have been mosquito control, their main use being in
treated, they should not be washed again urban and periurban areas, especially
until just before re-treatment (normally against culicine vectors. Drains and gutters
can be sprayed and temephos added to water ment to make it unsuitable for the vector.
containers and septic tanks. Surface sprays This can include simple methods such as
must be renewed at regular intervals. burying tin cans or cutting holes in old
To control Culex quinquefasciatus, the tyres to drain water, to clearing vast tracks
main vector of urban filariasis, which breeds of forest for tsetse fly control. Any method of
in latrines or soakaways, expanded poly- environmental modification on a large scale
styrene beads can be placed in the pit. The must carefully consider other systems that
beads float on the surface of the water so may be damaged. Clearing large areas of
larvae are dislodged and prevented from forest can affect the water retention of the
breathing, while the function of the latrine soil and deforesting river banks can lead to
or soakaway is not disrupted. The polystyr- severe erosion. On the other hand, filling-in
ene is manufactured as fine granules and or draining a swamp can provide extra land.
when placed in boiling water, it expands Eucalyptus trees, which absorb large
into beads. amounts of water from the soil, can be
planted and at a later time, their wood can
Biological control The term biological con- be used.
trol is used to describe the natural method of Specific methods of environmental
reducing vectors. Various natural agents modification, such as for trypanosomiasis,
that have been tried include predators such will be found under the particular disease,
as larvivorous fish, microbial organisms while the emphasis here will be on mosquito
(e.g. Bacillus thuringiensis and B. sphaeri- control. One of the most successful methods
cus) or modification of the insect itself. Male for reducing surface water and preventing
insects can be sterilized by radiation or with breeding places is the construction of sub-
chemosterilants and then released into the surface drains. This should be within the
environment. If these sterile males compete ability of most health personnel. The system
successfully with the unsterilized males, of drains should follow the contours
then the females will not be fertilized. Un- (Fig. 3.10) and be at least 1.5 m below the
fortunately, this technique requires the surface. The gradient needs to be between
preparation and release of a sufficient 1 in 400 and 1 in 30. Various materials
number of males to outnumber those in the can be used for constructing the drains,
natural habitat, which is generally imprac- such as stones, bamboo or poles laid
tical. An alternative technique is to breed length-wise in the bottom of the drain. An-
mosquitoes that are refractory to the target other method of environmental control is to
disease. This can either be through genetic use a siphon, which flushes out mosquito
manipulation or by introduction of a closely larvae, or a simple dam as shown in
related natural species. Species replace- Fig. 3.11.
ment, as the method is called, offers some
promise because similar, but competitive
species can be obtained from different parts
3.4.2 Insecticides
of the world.
The problem with any biological
method is that nature requires a balance. If Insecticides for vector control include the
a predator destroys all its food supply, then following:
it will die. As a result, an equilibrium is
reached where the number of predators and 1. Poisons (e.g. Paris Green, which was used
those they prey on remain in sufficient extensively as a larvicide). Anopheles
numbers for both to exist. Biological control gambiae was eradicated from Upper Egypt
is, therefore, more an aid rather than a by this preparation. In view of the resistance
definitive method. to insecticides that has developed, it could
be reconsidered.
Environmental modification In some situ- 2. Fumigants (e.g. hydrogen cyanide,
ations, it is possible to modify the environ- methyl bromide and ethyl formate) can
58
Chapter 3
page 58
Fig. 3.10. Contour drains in a (A) narrow ravine and (B) wide ravine. (From Davey, T.H. and Lightbody, W.P.H. (1987) The Control of Diseases in the Tropics.)
Fig. 3.11. A locally constructed dam for the control of Anopheles fluviatilis in Nepal. Every 3 days, the bung is
removed and the head of water rushing down the stream is sufficient to dislodge developing mosquitoes.
be used on grain or clothing to destroy temephos (Abate) are low-toxic compounds

infestations. widely used as larvicides.
3. Knock-down (e.g. pyrethrum, bioresme-
thrin and bioallethrin). Carbamates Carbamates act in a similar
4. Residual, which are sub-divided into manner to the organophosphates except
organophosphates, carbamates and pyreth- that they compete with acetylcholinesterase
roids. (Organochlorines, 4,4-dichlorodiphe- rather than combining with it, making their
nyl-1,1,1-trichloroethane (DDT), benzene effects more easily reversed and thereby
hexachloride (BHC) and dieldrin, which conferring an advantage to humans.
were widely used originally, are no longer Examples are propoxur and carbaryl.
available due to their toxic and long-lasting
effects on the environment.) Pyrethroids Pyrethrum is a naturally occur-
ring insecticide, obtained from a species of
Organophosphates Organophosphates, such chrysanthemum, that has been synthesized
as malathion and fenthion, are volatile sub- to produce a range of more active forms with
stances that require frequent application. good residual ability. These are stable sub-
They act by inhibiting cholinesterase at the stances with low mammalian toxicity and
nerve junctions and, therefore, can produce are widely used both for agricultural and
temporary paralysis (and respiratory failure) medical control. Examples are permethrin,
in humans as well as insects. They do not deltamethrin and lambda-cyhalothrin,
have a long residual action or persist in the which are particularly valuable for treating
environment. Chlorpyrifos (Dursban) and mosquito nets.
60 Chapter 3
3.4.3 Resistance . regular and effective washing of clothes

and bedding;
When an insecticide is being chosen for a . repellents;
control programme, the vector must be . improved house construction;
tested against various strengths of the in- . insecticides.
secticide to determine the discriminatory
dose (this is when 99.9% mortality of Ectoparasites favour dirty dark places,
the sample occurs). These tests need to be whether they are searching for a suitable
repeated from time to time during the course habitat on a person or a vantage place in the
of the programme to determine whether the house from which to mount an attack. Fleas
vector remains sensitive. If there are tech- and lice are not removed by washing, but the
nical reasons why this cannot be done, continued use of warm water and soap con-
then resistance will probably only be no- siderably deters them. If this is combined
ticed by an increase in number of insects or with washing of clothes, then fleas can rap-
cases of the disease. This might, however, idly be controlled. Where possible, clothes
indicate deficiencies in the spraying pro- and bedding should be boiled or at least sub-
gramme and these should first be ruled out. jected to very hot water as fleas are not
Correct application of insecticide can be affected by cold water. Some communities
measured as mentioned above, while a practice head shaving to control lice, while
simple field test for suspected resistance short hair makes them easier to control.
can be performed by placing a few of the Fleas and lice favour overcrowded con-
insects in a glass jar held against the sprayed ditions, such as those occuring during wars,
surface for a minute. If they are not all killed, famines or refugee camps. Efforts should be
then resistance should be suspected and en- instituted to reduce overcrowding, but
tomological assistance obtained. where this is impossible, washing and
Resistance may be partial or complete. laundry facilities should at least be pro-
If partial, then increasing the concentration vided. Wearing of other peoples clothes or
of insecticide may be sufficient to control sharing combs are common methods of
the vector. Unfortunately, complete resist- transferring ectoparasites in tropical areas.
ance is soon likely to develop. Resistance is Repellents have been used successfully
a genetic character and resistant strains are in areas where infection is likely. Impreg-
selected out under pressure of insecticides. nated socks and trousers can be effective
Initially resistance to one insecticide oc- when passing through micro-habitats of
curred, but subsequently cross-resistance scrub typhus or wild rodent plague. Ticks,
has developed making several insecticides bedbugs and reduviids are repulsed by repel-
ineffective. Some species now have mul- lents.
tiple resistance. Biological control or trying Bedbugs, ticks and reduviid bugs live in
a completely different strategy may be cracks in the walls of poorly constructed
effective. houses, coming out at night to attack sleep-
ing persons. Improving house construction
or applying a layer of unbroken plaster to a
3.4.4 Ectoparasite control wall discourages these arthropods perman-
ently. Bed nets can protect the individual
Ectoparasites live on the outside of the body, from being bitten.
such as fleas, lice, bedbugs, mites and ticks. Insecticides are especially useful in epi-
They are responsible for transmitting a demic conditions. Dusting clothing, using a
number of diseases covered in Chapter 16. puffer to supply the insecticide up trouser
There are various control methods: legs and skirts and down collars and sleeves,
can quickly reduce the number of ectopara-
. personal hygiene; sites in concentrations of people. Insecticide
. reduction of interpersonal contact from solutions can be applied to the hair to kill off
overcrowding and clothes sharing; head lice or to clothing if repellents are not
available. Rat burrows and runs should be 15.7 and 15.8). However, an MDA needs to
dusted with insecticides to kill off plague- cover the entire population in the infected
carrying fleas before rat catching. Benzyl area and the full dose of treatment seen to be
benzoate or BHC is effective against scabies swallowed. This becomes an administrative
mites. exercise requiring a large number of assist-
ants to ensure that the drug has been properly
taken. One of the most successful campaigns,
3.5 Treatment and Mass Drug in the Pacific Island of Samoa, used womens
Administration groups who are a very well-organized
segment of society, with the result that the
Treatment of the sick is not only a humani- coverage was over 90%. Generally, such
tarian action, but reduces the length of organizations are not available resulting in a
illness and, therefore, the period of commu- lower coverage rate.
nicability, thereby aiding control. However, Mass treatment is also used in the con-
where treatment is incomplete, it can actu- trol of trachoma (Section 7.5). Treatments
ally prolong the period of communicability, and MDA regimes will be found under the
encourage the development of carriers or relevant diseases in Chapters 718.
worst of all, resistant organisms. Case find-
ing and treatment is the main method of
control for leprosy (Section 12.6) and tuber-
culosis (Section 13.1), but careful follow-up
is essential to ensure that treatment is taken 3.6 Other Control Methods
for the whole period. Rapid diagnosis and
treatment is particularly important in acute The zoonoses often require specific control
respiratory infections (Section 13.2) and methods to reduce or eliminate the animal
meningitis (Sections 13.6 and 13.7). The reservoir. Dogs are the major animal source
development of effective single dose therapy of human disease (Table 17.1) so only those
for the treatment of the sexually transmitted animals which are useful in the society,
infections (STIs, Chapter 14) has been one of should be kept, and strays and unwanted
the great challenges of chemotherapy, dogs should be destroyed. Laws to reduce
but the power of the needle has also been dog-fouling are reasonably effective in
the means of transmission of several com- developed countries and could perhaps be
municable diseases. In many societies, applicable to urban areas of some developing
having an injection (irrespective of what is countries.
given) is seen as the panacea of all ills, but Rats are a serious transmitter of disease,
unfortunately improperly sterilized needles especially plague (Section 16.1), leptospir-
(including intravenous infusions) have been osis (Section 17.8) and Lassa fever (Section
responsible for much of the transmission of 17.9). Methods of controlling rats will be
HIV infection and hepatitis B. found in Box 16.1. Other methods of disease
Mass drug administration (MDA) is used control and prevention will be found under
as a method of control of filariasis (Sections the specific diseases.
4
Control Strategy and Organization
The first two chapters covered the elements several events can be carried out at the
and theory of communicable diseases and same time.
the previous chapter discussed how to inter- Excess cases, unusual deaths, exceed-
rupt transmission with the various methods ing the epidemic threshold or an unex-
of control available. This chapter considers pected clustering of cases will be indicators
how to put all this information into action that an outbreak of a new or known epi-
when faced by an outbreak, or the applica- demic disease is taking place. The cause
tion of control methods in an established will need to be identified and an estimate
endemic disease. made of the magnitude and distribution of
cases. Field investigations are organized
and active surveillance set up to find any
new cases. The disease can be confirmed
4.1 Investigation of an Outbreak by using an agreed case definition, specific
laboratory test or sero-epidemiological
In any communicable disease outbreak, the technique. The disease must be notified
following sequence of events will need to as soon as possible, both nationally and pos-
take place: sibly internationally (see Chapter 6). Judge-
ment needs to be used in spending time
. outbreak detection; on making an accurate diagnosis, or starting
. investigation; treatment with the information that is avail-
. confirmation; able. There will be great pressure to treat
. notification; cases, which is a necessary humanitarian
. analysis; action, but until transmission is interrupted
. treatment of cases; more cases will occur. Once the disease
. interruption of transmission; is under control, methods must be imple-
. prevention of recurrence; mented to prevent recurrence. Finally,
. analysis and writing of a report; the outbreak is analysed and written up.
. surveillance. A surveillance system is on the look-out for
the first indications of the communicable
These are not mutually exclusive stages, disease starting again. These stages will be
and although they are in order of action, considered in more detail.
62
Control Strategy and Organization 63
4.1.1 Identification pillars of epidemiology persons, place

and time. Information should be collected
The start of an epidemic can be dramatic from as many angles and from as wide a
with a large number of cases being reported field as possible. The more pointers there
or many people dying. However, the cause are to a method of transmission, the stronger
may well be anticipated, as the agents of will be the case.
most communicable diseases are now It will generally not be possible to com-
known. The person reporting the outbreak plete a detailed epidemiological investiga-
will probably have made a provisional diag- tion before starting some control methods,
nosis or it might be anticipated, having been for example, if it is diarrhoeal disease, then
reported in a neighbouring region. It will emergency boiling of drinking water can be
need to be confirmed by laboratory methods started. However, a full investigation must
or by careful clinical judgement (e.g. be made and completed, as quite often dif-
measles). A case definition is a useful tool ferent factors come to light. A full investi-
for ensuring that everybody understands gation will help prevent a recurrence.
what they are looking for. This can either The method used in an epidemiological
be very general, such as fever with no obvi- search is as follows:
ous cause as in a suspected malaria epi-
demic, or a more detailed description, such 1. Look for a common event that is shared
as with the rash and symptoms of measles. by all the cases.
In the general case definition, this will indi- 2. Study exceptions to see if there are
cate that laboratory confirmation is re- rational explanations.
quired, as in the example of malaria with a 3. Base these findings on the population at
blood slide being taken. risk.
Normally, the confirmation of diagnosis 4. Elucidate changes that have occurred in
is relatively easy, but several laboratory the environment, which may have favoured
specimens may be required and restraint the outbreak.
exercised in rushing to a diagnosis (e.g. in 5. Make a hypothesis of cause, route of
typhoid). Alternatively, it may be a unique transmission and method of control.
and rare disease in which the aetiology and
transmission have not been worked out. If Ideally, information should be collected on
this is the case, expert assistance is sought, every case, but this might be scant or absent
while general principles of control are in the first few cases. However, it is import-
carried out. ant to investigate these first cases thor-
Enquiry and search is made to deter- oughly so that the start of the epidemic can
mine the extent of the outbreak, whether be accurately fixed and an epidemic curve
there are many more cases, especially in drawn (see Chapter 2). If it is a very large
areas where there are no medical facilities. epidemic, then it might be preferable to take
Cases may be hidden or exaggerated to avoid a sample of cases and study these in detail,
or attract medical attention. Is this the first but some record of the total number of cases
case or have there been several cases over a will always be required.
period of time? Have the cases come from Information on persons should be avail-
another administrative area or country, and able, and sex and age classification can read-
is there a risk that they might infect other ily give an indication as to the cause of the
areas? Was notification received and should epidemic. If it is just children who are in-
notification be given? volved, then it is a common disease in
which adults have obtained immunity such
as measles. If there are more cases in one sex
4.1.2 The epidemiological investigation than another, then this might indicate a div-
ision of duties such as women (who are the
Collecting information on the cause and main collectors of water) succumbing to
method of transmission utilizes the three cholera in larger numbers than men.
64 Chapter 4
The address of each case should be plot- person and place data. Laboratory confirm-
ted on a map and a note made of the most ation of cases might give a different pattern
affected areas and whether there is any clus- from clinical assessment, especially where
tering. Look for associations, such as rivers, several medical staff are involved. If avail-
breeding places of vectors, forests that might able, samples might need to be taken from a
harbour reservoir animals, or any other fea- suspect cause, such as a food item, or from
ture that the nature of the disease indicates the environment, such as a river used for
to be important. If maps are not available, drinking water, which will all take time to
then constructing a simple sketch map be analysed. However, a negative result will
might be necessary, especially if it is a very not necessarily alter the hypothesis; the spe-
well-defined epidemic. Typhoid cases often cimen may have been collected too late or
occur in communities, so the houses of indi- from the wrong place. It is the strength of
vidual victims will need to be identified on a association of all the different pieces of evi-
sketch map of the village or town. Any clus- dence that should be used to decide on the
tering or association of cases might lead to cause.
the carrier from which the epidemic started.
Exceptional cases can often provide defini-
tive evidence of an association such as the 4.1.3 Treatment of cases
visit by a person resident in a different area,
which subsequently becomes infected.
The priority is to organize the treatment of
All calculations, such as the morbidity
cases rather than become involved in the
and mortality rates, must be done on the
clinical management, and concentrating
population at risk. Normally, this is the
time on investigating the outbreak and insti-
population of the entire area, district, region
gating control. This should be by:
or country, but in a very localized epidemic,
the population of the village, town or group
of villages might give a better estimate. . setting up emergency treatment centres or
Population figures are available from census arranging transport of cases to hospital;
data, malaria control programmes and often . mobilization of staff, medicines and equip-
collected by the village authorities. Other- ment according to need;
wise, a sample needs to be taken of the . formulation of a standard treatment
number of occupants in a random number schedule;
of houses, followed by counting of all the . making rules on period of quarantine,
houses in the area and multiplied by management of contacts, prevention of
the average house occupancy. carriers and disposal of the dead.
There is normally a reason why an epi-
demic has occurred at a particular period in As the epidemic means a large number of
time. Diarrhoeal diseases often start at the cases of a single disease, once the diagnosis
beginning of the rainy season and influenza has been made, the treatment of all the cases
is more common during winter months. Reli- will be the same. There may be a compli-
gious gatherings or other large collections of cated case that requires special attention,
people provide ideal conditions for the trans- but the priority of the investigating doctor
mission of disease. If there are strong indica- is to interrupt transmission and bring the
tors, then these can be used in future epidemic to an end. A standard treatment
surveillance and to initiate preventive action. schedule should be devised and all available
A working hypothesis is established as staff at every level made available to help
soon as possible so that emergency control with treating the cases. Instead of trying
action can be commenced, but a detailed to bring all the cases to a hospital, it may
investigation must be completed. Search be better to set up emergency treatment
back within the maximum and minimum centres in the proximity of the outbreak.
incubation period from the first case or Schools, community centres, religious
cases using other indicators gained from buildings and warehouses can be utilized
for this purpose. Not only does this avoid deaths are items of information that author-
the problem of transporting cases, but frees ities are particularly interested in. The func-
the hospital from fresh contamination or dis- tions of a report are to:
ruption.
. inform planning and organizing author-
ities of what has happened;
. notify other workers who are or might
4.1.4 Interruption of transmission
soon be participating in a similar out-
break;
Once a hypothesis of causation is made from . make a record to be referred to in future
the epidemiological investigation, a method outbreaks;
of control is commenced. This can be done . evaluate actions taken and improvements
in three different phases: that should be made;
. provide information for the general
. emergency; public;
. specific; . elicit funds for more permanent prevent-
. long-term prevention. ive measures;
. illustrate for teaching purposes;
If the communicable disease is in epidemic . be used for the advancement of science if
form and threatening a large number of of an original nature.
people, then emergency methods must be
implemented as soon as possible. These are
often non-specific and should commence 4.1.6 Outbreak organization and community
before the detailed investigation has been participation
finished. As an illustration of these three
different strategies, an epidemic of dengue
Outbreaks occur suddenly and often with
can be used. The emergency method would
little warning so there is no time to wait
be a knock-down spray, such as fogging
for help to arrive; the doctor, nurse or
which kills all adult mosquitoes indiscrim-
other health worker must take control.
inately. This will control the immediate
Generally, the temptation is to become so
problem, but once the number of adult
involved in patient management and treat-
mosquitoes builds up again, the epidemic
ment that no investigation is done. But until
might recommence. The specific method
the cause of the outbreak is investigated,
would be a programme selectively against
cases will continue and generally increase
the Aedes mosquito vector by destroying
in number.
all temporary breeding places and using
Help in patient care can be obtained
larvicides in water containers. Long-term
from many sources, such as other health
prevention would be by permanently
workers, public health inspectors, hospital
altering breeding places, placing mosquito
porters, even cleaning staff, but probably the
netting over water tanks, repairing broken
main resource will be relatives. In most soc-
guttering and all the techniques that are
ieties, relatives will come with the patient
available for removing the mosquito per-
and remain with them until they are cured.
manently.
Care needs to be taken that they do not
become patients themselves if it is a highly
infectious disease, so instructions on pre-
4.1.5 Analysis and report ventive methods will need to be given and
enforced.
A communicable disease outbreak should In many communities, there is a
be analysed in detail and written down as a local organization that should be involved
report. This will be based on the investiga- at an early stage. This may be official, a vil-
tions made, the control methods used and lage chief or headman; religious, the village
their outcome. The number of cases and priest; or just a respected member of the
66 Chapter 4
community such as a school teacher. In not bother to collect the information or even
some countries, the local organization will worse, to falsify the data. Even the routine
have a person responsible for the health of data already collected should be looked at in
the community or a village health commit- detail; for example, staff may record the
tee. They will be of value in identifying number of patients reporting headaches,
cases, but even more useful in seeing that which will not be a valuable criterion.
control measures, such as boiling drinking Recording fever rather than headache (and
water, are enforced. They will also have a taking a blood slide) is far more useful.
role in preventing the epidemic from Accuracy of data collection can be im-
starting up again in the future, such as en- proved by training, with regular refresher
suring that all children are vaccinated. courses so that all staff are taught the same
method at the same time. Regular feedback
of an analysis of the data will encourage staff
to be vigilant in their returns. Comparing
4.2 Surveillance
one area with another will show up weak-
nesses, which can then be strengthened.
Surveillance of communicable diseases Formulating case definitions encourages a
is the continuous watching for any changes more consistent diagnosis.
in known diseases and the monitoring of Where facilities are available, labora-
the environment for any new diseases that tory confirmation is always desirable. Every
may appear. fever case in a tropical area should routinely
The key to surveillance is reporting, de- have a blood slide taken, and sputum smears
veloped in such a way that a continuous always made from persons with a chronic
record is kept, not the desperate call of cough. In special circumstances, having a
an established epidemic. Surveillance screening programme can enhance routine
methods are of several kinds and are dis- investigations. Examples are antibiotic re-
cussed below. sistance patterns of STIs, Aedes aegypti
index in dengue-susceptible areas, vaccine
coverage in under-fives clinics and rainfall
4.2.1 Routine or passive surveillance records to measure seasonality.
All data collected must be analysed or
All health facilities collect data in their there is no point in collecting it in the first
record keeping, at its simplest being the place. The well-established criteria of per-
name, age and sex of the individual and the sons, place and time will be the basic model,
symptoms or diagnosis of their illness. but special techniques may also be required.
Considerable use can be made of well-kept Data from one level are sent to the next
records and it is worth doing an analysis of higher level where they are analysed, and a
the type of information collected to deter- copy of the analysis sent both to the level
mine the best system to use with the above and to those collecting the data in the
resources available. Hospital records, while first place. Special reporting may be re-
more detailed than in small clinics, will not quired for notifiable diseases. Evaluations
be representative of the population. need to be made at regular intervals to
Additional categories can be added to modify and improve the system.
the basic data collected, but care must be
taken not to overload the health staff so
that an unreasonable amount of their time 4.2.2 Active surveillance
is taken up with filling in forms. Every add-
itional entry must be tested by a small pilot Active surveillance is the deliberate search
study to ensure that it is collecting the infor- for target data. This has been used particu-
mation required and is within the means of larly in malaria control programmes, where
the staff to collect it. If it is too onerous a contacts of malaria cases are visited and
task, then there will be a tendency to either blood slides taken, as illustrated in Fig. 4.1.
Fig. 4.1. An active case detection (ACD) technician taking a blood slide from a woman suffering from fever in
a malaria eradication programme (St Isabel, Solomon Islands)
Another example is a leprosy field worker as contacts and bacteria counts, among
who visits all the villages in his/her area and others. Suspect cases or contacts should be
examines the population for any signs of kept under observation. Monitoring of treat-
early disease. Suspect cases are then sent to ment can detect the appearance of resistant
clinic or hospital for further tests. organisms or an imbalance in the treatment
regime. Utilization of staff and equipment
can also be built into an emergency surveil-
4.2.3 Sentinel health service surveillance lance system.
Special health problems involving detailed

or laboratory investigation are often best col- 4.2.5 Serological and virological surveillance
lected by using sentinel health services.
These are given extra staff or facilities to Where laboratory facilities permit, a record
enable them to identify the disease. Influ- of certain diseases can be obtained from
enza information is often collected in this serological or virological studies. An
way, as it is notoriously difficult to distin- example is the use of anonymous testing of
guish influenza from the common cold and blood samples collected at antenatal clinics
other causes of a respiratory infection. Sev- for HIV and hepatitis B infections. Care must
eral sentinel health centres will then give a be taken to ensure that the data are represen-
reasonable estimate of the problem in the tative of the population and are measured
entire area. continuously.
As the incidence of a parasitic disease
declines, it becomes increasingly difficult to
4.2.4 Emergency surveillance detect the parasite and serological surveil-
lance can be of more value. This method has
Emergency surveillance is set up during an been used in malaria programmes nearing
outbreak to monitor special risk areas, such eradication.
68 Chapter 4
4.2.6 Other forms of surveillance

Control Eradication
Where all information reaches a single cen-
tral authority, it is reasonable to assume that Objective Minimal Complete
it is representative of the entire area from incidence elimination
which it is collected. An example would be Duration Indefinite Time-limited
a public health laboratory, where more com- Coverage Areas of high Entire area
plex and standardized results are available. incidence
Other allied disciplines may collect Method Effective Faultless
data that is relevant to health, such as veter- Reservoir Animal or Human only
environment
inary and entomology services. Sleeping
Organization Good Perfect
sickness is a more widespread and devastat- Costs Moderate for a High for limited
ing disease in cattle than humans, so out- long time period
breaks in cattle are indicators to take Complications Acceptable Extremely
precautions in associated human commu- serious
nities. Anthrax and bovine spongiform en- Imported cases Not important Very important
cephalopathy (BSE) are other examples. Surveillance Reasonable Very good
Epidemics may first be reported by
persons in authority, such as village leaders,
school teachers, priests, etc. Indeed, they healths greatest triumphs against disease.
can often be relied upon to give continued This was only possible because the vaccine
and reasonably accurate information for was extremely effective, there was no other
the community they serve. It is often one reservoir but humans and the organization
of the functions of a village leader to was very good. Recently, an entirely differ-
collect data on births and deaths, which ent kind of disease, Guinea worm, has been
can be valuable in estimating the popula- eradicated from all countries except one
tion. (where there is a civil war) by a programme
More information on surveillance can of protected-well construction. Poliomyel-
be found in Section 5.3 and under each itis has been eliminated from WHO regions
disease in Chapters 717. of the Americas, Europe and Western Pacific
and in 2001 only 600 cases were reported
from the rest of the world. The global yaws
campaign eradicated yaws from large areas
4.3 Control and Eradication of the world, but it is still endemic in some
places and on the increase in others. The
A communicable disease can be controlled tremendous progress of the malaria eradica-
or eradicated. By controlling a disease, it is tion campaign, followed by an equally im-
kept at such a minimum level that it no pressive resurgence of the disease, has been
longer poses a health problem. Eradication a devastating setback to the doctrine of
on the other hand sets out to eliminate the eradication. (There have been other local-
disease completely. The difference between ized eradication programmes such as
control and eradication can be summarized Anopheles gambiae from South America.)
in the following table. With eradication, it is an all-or-none pro-
The attraction of putting the entire cess if eradication is not complete, then the
health effort, funded by international sup- disease can return to its former levels and all
port into the eradication of a disease requires effort has been wasted. In these circum-
organization of the very highest order. There stances, it is preferable to choose the alterna-
have been five global eradication efforts, out tive target of control, which will be the
of which two were successful, the other two method used in the majority of infections.
almost successful and the remaining one A new terminology has been introduced
was not successful. The eradication of small- by WHO elimination. This uses a special
pox worldwide has been one of public programme and enhanced resources similar
to an eradication programme, but accepts vices for a brief special effort, which can
that eradication will not necessarily be continue to be maintained in their routine
achieved. Lymphatic filariasis, Chagas dis- services. An example is a mobilization of the
ease, trachoma, maternal and neonatal tet- general health services to do a mass vaccin-
anus have been designated as suitable for ation campaign before the start of the rainy
elimination programmes. season (Section 3.2.6). For the rest of the
year, they can continue with the routine
vaccination programme.
4.4 Campaigns and General Programmes
Communicable diseases can be controlled 4.5 Control Organization

by campaigns (called special programmes
by WHO) or made a function of the general During the malaria eradication campaigns, a
health services. Special campaigns have the high level of organizational methodology
attraction of putting all the effort into one was developed, which is a useful model for
particular disease, often with considerable any communicable disease control pro-
initial success, but over the long term, break- gramme. The four stages are as follows:
ing down again. Integrating the control
method with the general health services . preparatory;
often gives a more consistent result. The ad- . attack phase;
vantages and disadvantages are as follows: . consolidation;
. maintenance.
General health
Campaigns services 4.5.1 Preparatory
Effectiveness Initially very Only moderate
good The preparatory stage is perhaps the most
Continuation Poor Moderate important, and time spent on collecting
Duration Short Long baseline data, trying to forecast problems
Staff Special General health and assessing the feasibility of the proposal
required workers is always time well spent.
Salary Inflated Average Surveys are made of the disease to
Staff problems No career Addition to measure its prevalence over as wide an area
structure routine duties as possible. A good sample survey might be
Cost High Low
sufficient to measure the endemicity, but
Integration Low High
this will not reveal the foci of infection,
which normally cause the most problems.
It is the integration of the campaign into the In addition, a surveillance system needs to
general health services that destroys the be established, if there is not one already, to
good progress made. There are difficulties continually collect data on cases as the pro-
of emphasis, staff absorption and resent- gramme proceeds.
ment by the multi-purpose worker. Cam- The population will need to be enumer-
paign workers are often specially recruited ated and it might be justified to spend
for the task, probably from non-medical money on carrying out a census if one has
backgrounds and are paid inflated salaries not been done recently. Maps are essential
to offset the time-limited nature of the oper- and if suitable ones are not available, then
ation. The general health services are not they need to be drawn. They must contain
used to dealing with the special disease up-to-date village locations, preferably with
and feel they are being given extra work, the population marked on them. Figure 4.2
while still being paid the same. An alterna- is an example of a map prepared in this
tive might be to use the general health ser- way.
70 Chapter 4
Ipinda
Mpunguti
1081 llopa
Masebe Mbaka
1254
1951
1529
Ndola 2657
Kasala 1498 1965 Lugombo
Tenende (Mwaya)
Itope M Lake
ba
Kikusya si
1343
1292 Nyasa
(Itungi Port)
1166
1799 Kilasilo (D) Nkuyu
1743 Itunge
Ibungu Kajunjumele
Ndandalo 4906
(D) 2220
2135 Isaki 1971 Kyela 1982
2166
Kilwa (D)
Kingila 1902 2560
Itope Lubaga
1956
(Bujonde)
(D)
So
ng 1183
we 1727 Njikula Isanga
1163 Ndwanga (Mungano)
Nsasa
1133
Ngonga (D)
Itenia
2572
1181
1996 Ikolo (D)
1759 Lugombo
N Mpunguti
1434
Katumba
2222
(D)
0 5
Kilometres
Key
All weather roads 1965 Village with census
Tenende population
Other roads
(D) Dispensary
International boundary
Swamp
District boundary
Bridge
Ford
Fig. 4.2. Part of a village location map prepared for a disease control programme.
Every level of society must be commit- 4.5.2 Attack

ted from the senior administrative head,
through divisional chiefs and influential In the attack phase, the method that was
people, to the established health worker. found to be effective in the pilot programme
This will require regular meetings, with the is extended to the whole area. Alternatively,
establishment of key contacts. Without the area can be covered in sequence, but if
the complete and continued cooperation of this is done, then measures may need to be
the people, any special effort is doomed to instituted to prevent re-infection. Time
failure. tables and procedures are required to ensure
Planning of the persons, money and ma- that separate teams cover the area in a regu-
terials (logistics) to be used in the pro- lar manner. Realistic targets are set and or-
gramme is often the easiest part to initiate, ganization developed to make sure they are
but one of the most difficult to maintain. kept. The delay in one part will cause the
Utilizing existing staff who retain all their delay of everything else.
usual functions and continue in an estab- During the attack phase, the number of
lished pattern of service is preferable to re- cases found by the passive surveillance ser-
cruiting special staff, but this should not be vices will rapidly diminish, so progress is
at the expense of existing services. If special assessed by making serial surveys. Inci-
staff need to be recruited, then conditions of dence is more useful than prevalence data;
service must be carefully worked out so that therefore, surveys are conducted at regular
no conflict arises with existing staff. intervals in sample areas. However, this can
Adequate funding is required, as no dispose a strain on relations with the popula-
ease control programme has remained tion that is being sampled and areas of
within estimates; they nearly always cost higher prevalence may be missed, so new
more than expected. Additions arise that sample areas may need to be used after a
were not foreseen, inflation increases faster time.
than allowed for and the programme takes To ensure that all the remaining cases
longer than planned. If adequate finances are found, an active surveillance system
cannot be secured and the programme has can be established. This involves special
to be abandoned, then the net result is worse workers, each with an assigned area
than doing nothing in the first place. More which is visited on a regular basis. Active
serious is the damage done to the existing surveillance is no substitute for passive sur-
health services by diverting funds from veillance, the two should work closely
them. together.
Included in the preparatory stage is a
pilot programme to try out the techniques
and organization in a limited area. The
pilot programme is a scaled down version 4.5.3 Consolidation
of the full programme, not a special effort to
show what can be done. The area chosen In the consolidation phase, the full appar-
should be fully representative of the larger atus of disease reduction is disbanded and
area to be covered. If there are marked vari- reliance placed on small specialist teams
ations, then several pilot studies of differing that can rapidly respond to the active sur-
criteria may be required. veillance system. If a focus of malaria is
The pilot programme can be for a set found, then focal spraying and radical treat-
period of time, or continued into the full ment of cases is implemented. If a yaws or
programme after it has been assessed. If polio case is suspected, then mass treatment
there are major difficulties, then the pro- or vaccination is given in the surrounding
gramme should proceed no further, but the area. The essence of the consolidation phase
whole strategy reworked. If there are minor is speed and efficiency. If rapid remedial
problems, then these are indicators of major action cannot be carried out, then the dis-
problems in the future. ease is liable to return.
72 Chapter 4
4.5.4 Maintenance or a continuing level

of control amount of funds and staff availability per-
mits, then this might need to be continued
If the target of the programme is to eradicate indefinitely. A limited control programme
the disease, then the maintenance phase may be sufficient to reduce the burden of
will be an efficient monitoring system disease to allow a rise in the standard
to ensure that any introduced cases are rap- of living, which in the long term will have
idly detected and treated. If it was to reduce the most sustained effect on controlling the
the disease to an acceptable level that the disease.
5
Notification and Health Regulations
Due to the serious nature of a disease . paralytic poliomyelitis;

or the ease by which it is transmitted, . malaria;
some diseases are notifiable. Individual . influenza;
countries will have their own priorities as . human immune deficiency virus (HIV);
to which diseases these should be, whereas . smallpox;
international agreement specifies certain . severe acute respiratory syndrome
diseases which must be notified to other (SARS).
countries, generally via the WHO.
The initial case is notified by e-mail to
www.who.int/csr/alertresponse and subse-
5.1 International Health Regulations quent summaries of the number of cases sus-
pected and confirmed are sent at weekly
International health regulations require intervals.
that certain diseases be notified. The The regulations are being revised and
purpose is to warn other countries and instead of the current list of three diseases,
intended travellers to the country of the this will be replaced by a requirement for all
health risks involved. Assistance can also countries to notify WHO of all diseases or
be requested, once the disease has been events of international public health import-
notified. ance. This will mean that such events, as
Diseases subject to the International the first cases of a new infection, such as
Health Regulations (1969, 1974 and 1992) SARS, must be reported.
are as follows: In addition, a region (e.g. the South
Pacific Commission or Association of
. plague; Caribbean States), may initiate its own regu-
. cholera; lations, for example, for the following
. yellow fever. disease:
Diseases under surveillance by WHO are as . dengue;

follows: . diphtheria;
. typhoid;
. louse-borne typhus; . whooping cough;
. relapsing fever; . scrub typhus.
73
74 Chapter 5
5.2 National Health Regulations . any person or persons dying from diar-
rhoea;
Countries have their own system of national . any person dying of jaundice in the yellow
notification of some diseases, including the fever zone (see Fig. 5.1);
following: . Aedes aegypti index;
. severe case of chicken pox or other un-
. tuberculosis; usual pox rashes;
. leprosy; . any case of acute flaccid paralysis
. sleeping sickness. following a feverish illness;
. severe pneumonia with difficulty in
breathing.
5.2.1 Notifiable diseases for England and

Wales Any case coming within one of these cat-
egories is reported immediately to the re-
sponsible Medical Officer or doctor in
Very rare Common
charge, who is required to investigate the
infections Rare infections infections
report.
Anthrax Leptospirosis Food poisoning WHO has set up an international sur-
Leprosy Yellow fever Viral hepatitis veillance team to investigate any case of sus-
Typhus Cholera Whooping cough pected smallpox reported. The suspected
Relapsing fever Diphtheria Tuberculosis case must be isolated and WHO informed
Plague Poliomyelitis Malaria immediately. There is also concern about
Smallpox Typhoid fever Meningitis emergent diseases and the strengthening of
Viral Paratyphoid Meningococcal surveillance systems, so the linking of one
haemorrhagic fever septicaemia countrys reporting with another will assist
fever Rabies Ophthalmia
in detecting new diseases before they
Tetanus neonatorum
Encephalitis Measles
become a serious problem.
Dysentery
(bacillary and
amoebic)
Rubella 5.4 Vaccination Requirements
Scarlet fever
The only vaccination now required for inter-
national travel is yellow fever for persons
who come from or pass through a yellow
5.3 Special Surveillance fever zone (Fig. 5.1).
Cholera vaccination is no longer
The principles of surveillance were men- required by international regulations.
tioned in Section 4.2. A country at particular A yellow fever vaccination must be recorded
risk may be advised to set up a surveillance on the prescribed form with the signature
system of international or national import- of the doctor; the batch number and official
ance. Some suggestions are: stamp of the vaccination centre. The
vaccination is valid for 10 years, 10 days
. in plague areas, any case of fever, glandu- after the date of the vaccination or revaccin-
lar enlargement and death; ation.
Notification and Health Regulations 75
(Map 1)
TUNISIA
O
C
C
O
R
O
M
ALGERIA LIBYAN
ARAB EGYPT
JAMAHIRIYA
MAURITANIA
ERITREA
MALI NIGER
CHAD SUDAN
SENEGAL
GAMBIA
BURKINA
GUINEA- FASO
BISSAU GUINEA
D'IVOIRE
NIGERIA
GHANA
COTE
SIERRA LEONE ETHIOPIA

N
CENTRAL
RO
LIBERIA AFRICAN REPUBLIC

ME
IA
AL
CA
TOGO
M
SO
DA
BENIN
AN
GO
SAO TOME & KENYA
UG
CON
PRINCIPE GABON
RWANDA
EQUATORIAL BURUNDI
GUINEA UNITED
REPUBLIC OF
TANZANIA
CONGO
ANGOLA
ZAMBIA
ZIMBABWE
SCAR
QUE
MOZAMBI
AGA
NAMIBIA
MAD
BOTSWANA
SWAZILAND
LESOTHO
Yellow fever
endemic zone SOUTH
AFRICA
WHO 93636
Fig. 5.1. The yellow fever endemic zones in Africa (Map 1) and Central and South America (Map 2, see next
page). Yellow fever endemic zones are areas where there is a potential risk of infection on account of the
presence of vectors and animal reservoirs. Some countries consider these zones as infected areas and require
an international certificate of vaccination against yellow fever from travellers arriving from these areas.
(Reproduced, by permission, from WHO (2004) International Travel and Health, Vaccination Requirements
and Health Advice, World Health Organization, Geneva.)
76 Chapter 5
(Map 2)
PANAMA
VENEZUELA GUYANA
SURINAME
FRENCH GUIANA
COLOMBIA
ECUADOR
BRAZIL
PERU
BOLIVIA
PARAGUAY
CHILE
URUGUAY
ARGENTINA
Yellow fever
WHO 93637
endemic zone
Fig. 5.1. Map 2.

6
Classification of Communicable Diseases
No biological system is perfect and commu- provisos, all the communicable diseases
nicable diseases in particular are not readily are listed in Chapter 19, at the end of the
classified; however, any grouping makes it book, rather than here, so quick reference
easier to understand and remember, so the can be made to them.
objective of this short chapter is to look at There are 340 diseases listed in Chapter
the different ways this can be done. 19, of which the commonest causative organ-
A disease is a morbid condition of the ism is a virus, being responsible for 185
body (e.g. measles or plague). As the cause of diseases, with arboviruses causing 118
diseases were discovered, they became infections. Bacteria and chlamydia account
identified by the causative organism, such for 66 and the larger parasites for 54 infec-
as trypanosomiasis or pneumococcal men- tions, of which the nematodes cause 21 dis-
ingitis, but confusion arose because there eases, protozoa 17 and helminths 16. The
are two forms of African trypanosomiasis commonest method of transmission is, there-
and one of American, while the pneumococ- fore, the vector, with the mosquito being
cus is an important cause of pneumonia incriminated in a staggering 76 infections,
as well as meningitis. This confusion con- ticks in 31, and other or unknown biting
tinues. Instead of settling on one system insects in 42 of the infections. In methods of
or another, I have tried to list all the commu- control, with vectors being so frequent,
nicable diseases by either the disease state vector control is the commonest, which
or the organism by which they are best iden- proved useful in 134 of the disease condi-
tified. For example, in the case of gastro- tions, but simple methods, such as using re-
enteritis, one of the commonest causes of pellents and sleeping under mosquito nets,
diarrhoea in developing countries, it is pref- are all that are required most of the time. Next
erable to separately list the various organ- comes personal hygiene, invaluable for pre-
isms that can cause it. Where these are venting 90 infections just washing your
particularly distinct, such as rotavirus infec- hands, not spitting and making an effort to
tion, then they are put into the list. On be clean can be remarkably effective. Allied
the other hand, the streptococcus is respon- to personal cleanliness is food hygiene, en-
sible for such an array of diseases that just to suring that food is prepared properly, ad-
put down streptococcal infection would equately cooked and stored under safe
fail to reveal important diseases such as conditions, accounting for 57 of the prevent-
rheumatic fever or otitis media. With these ive methods. Allied to the proper cooking of
77
78 Chapter 6
food is the control of animals either in their diseases can be classified into 11 groups as
farming, slaughter, and the control of do- follows:
mestic pets, this group being responsible
for 41 disease preventive actions. Chemo-
Chapter
therapy as a method of control is valuable
in 40 diseases and vaccination in 35, but Water washed diseases 7
several of these are major disease problems, Faecaloral diseases 8
such as tuberculosis, measles and the STIs. Food-borne diseases 9
The provision of a good water supply will Diseases of soil contact 10
reduce 39 conditions and sanitation another Diseases of water contact 11
23, while the control of rats is important in Skin infections 12
17 conditions. The social and educational Respiratory diseases and other airborne 13
methods appropriate to controlling STIs transmitted infections
will be valuable in 20 conditions, while the Diseases transmitted via body fluids 14
Insect-borne diseases 15
screening of blood donors will avoid 14 dis-
Ectoparasite zoonoses 16
eases and the proper sterilization of needles, Domestic and synanthropic zoonoses 17
instruments and giving sets could prevent
nine diseases.
No attempt is made in the next few Water-washed diseases could be called
chapters to cover all 340 of the diseases person-to-person diseases, but many dis-
listed, but to select only those of worldwide eases including skin infections and respira-
importance, which are major problems in tory diseases are also transmitted from one
certain parts of the world, or to illustrate a person to another, so a preferable descrip-
particular disease pattern. Readers might tion is to include the main method of con-
find it useful to refer to the list in Chapter trol, which is washing. They could also be
19 first, before turning to the fuller descrip- called diseases of poor hygiene, but since
tion in the following pages. hygiene is involved in the control of very
Diseases are normally classified by many diseases, to call them this would
the causative organism, which has much make this category far too large. Faecaloral
to recommend it for the clinician and the is a very large group and could quite easily
pathologist, but different organisms can incorporate many of the diseases in the
cause similar diseases, such as Escherichia chapter on food-borne diseases, but it is
coli, a bacteria and Giardia intestinalis, a easier to consider control methods if a sep-
protozoa, both producing diarrhoea in the arate chapter is made. There are important
individual. Control methods are similar; as diseases that are acquired by contact with
a result, an epidemiologist will find it pref- either soil or water, which means that
erable to include them in the same group. methods of control are very specific. Skin
On the other hand, the closely linked group infections are obvious in their presentation
of viruses that cause hepatitis are very and most of them are transmitted directly by
different in their means of transmission skin contact but also use other modes of
hepatitis A is transmitted by the faecaloral transmission, so it is more convenient to
route and hepatitis B by blood and other classify them by their most common method
body fluids, so it is preferable to separate of presentation. Instead of putting leprosy in
these two diseases into different categories. a separate chapter as in the previous edition,
Transmission is the key to the epidemiology because its means of transmission has not
of communicable diseases. Once the means been fully worked out, it is included in
of transmission is known, it leads to the the chapter on skin infections. The respira-
best method of control, so it is preferable to tory infections are transmitted by the air-
use this as the method of classification. borne route, which is also a method of
Based on these criteria, all communicable transmission of several other infections
Classification of Communicable Diseases 79
that present in different ways. The chapter complexities of the many communicable
on diseases transmitted via body fluids is an diseases.
attempt to bring together common themes in The fewer groups there are, the easier it
the transmission and control of diseases is to remember all of them, sparing the oner-
transmitted via blood, seminal fluid, cer- ous task of learning about each disease in
vical secretions, saliva and other less detail. However, if each group is too broad,
common methods of transmission. It in- much of the essential information is also
cludes the STIs, which would warrant a lost, thereby defeating its purpose. For
chapter of their own, but other diseases example, Vietnam had classified all its com-
that share many common features, such as municable diseases into just four groups, but
hepatitis B and non-venereal syphilis, are this was found to lack the precision to work
better included with them. Insect-borne dis- out the best control strategy for each group,
eases not only include a large number of so this was replaced by an abbreviated clas-
health problems, but also some of the most sification, as follows:
important diseases in the world such as mal-
aria. It is already the largest chapter and 1. Person-to-person (skin and eye diseases).
could be even bigger, but the combination 2. Faecaloral transmission.
of ectoparasite transmission (by fleas, lice, 3. Soil-contact.
etc.) and zoonosis is a very specific one, so a 4. Airborne (respiratory infections).
separate chapter has been included for this 5. Diseases transmitted via body fluids
category. The rest of the zoonoses, where a (includes STIs).
vector is not included, form the last chapter 6. Vector-borne diseases.
in the classification. 7. Zoonoses.
No classification system is perfect and
not every disease fits neatly into the 11 cat- This simplification was due to the absence
egories. For many diseases, there is more of such diseases as schistosomiasis and
than one means of transmission and these Guinea worm, which are the only members
can also be important in developing control of the diseases of water contact in the clas-
methods. However, the categories are suffi- sification above, and several others, which
ciently broad to encompass minor differ- allowed amalgamations. Any country might
ences. Bringing them together into such a similarly like to draw up its own classifica-
system demonstrates similarities and asso- tion system based on the important diseases
ciations, making it easier to understand the found there.
7
Water-washed Diseases
The simplest disease transmission is by 7.1 Scabies

person-to-person contact (see Fig. 1.3). The
diseases of poor hygiene arise from direct Organism Infection of the skin is by a mite
contact of the skin, conjunctiva or mucous Sarcoptes scabiei.
membrane. Alternatively, organisms from
the skin or in conjunctival secretions can
Clinical features There is a skin rash and
be transported by an intermediate vehicle.
intense itching where the mite burrows
The essential mechanism is contamination
into the superficial layers of the skin. It
due to lack of hygiene.
favours the wrists and hands, although in
There are two groups of diseases in this
heavy infections, it may be found in almost
category skin diseases and eye diseases
any area of the body, but not the head or face.
and it is convenient to describe them in this
Due to scratching, the affected skin can
order. The skin diseases include infections
become thickened and discoloured leading
of scabies and lice and the superficial fungal
to a mistaken diagnosis of eczema. Second-
diseases. Tropical ulcers, for which a means
ary infection is common and glomerulo-
of transmission has still not been defined,
nephritis can occur.
are conveniently included here. The eye dis-
eases of significance in public health are
trachoma, epidemic haemorrhagic conjunc- Diagnosis is made from clinical presenta-
tivitis, epidemic keratoconjunctivitis and tion, but skin scrapings can be made and
ophthalmia neonatorum. the mite viewed microscopically.
The main method of control of the dis-
eases of poor hygiene is to increase water Transmission of scabies is due to close per-
quantity. They are the first category in sonal contact, permitting the mite to pass
Table 3.1 called the water-washed dis- from one person to another. It can be trans-
eases. Providing an adequate volume of mitted by shared clothing and is potentiated
water for washing encourages personal by poor hygiene. Where possible, infected
hygiene. individuals should be prevented from
80
Water-washed Diseases 81
infecting others, for example by keeping used in the control of malaria (Section
children away from school until they are 16.5.10) or the naturally occurring Chrysan-
cured of the infections. Careful search themum from which it is derived, is also
should be made for unreported or unrecog- effective. Reduction in scabies can be an
nized cases in the community. Scabies can additional benefit of insecticide-treated
be spread amongst adults as a STI. Intract- mosquito nets, otherwise permethrin can
able scabies in adults, not responding to be administered as a 5% cream or 1% lotion.
treatment, can indicate HIV infection. Ivermectin, used in the treatment of filaria-
sis and onchocerciasis (Sections 15.7 and
Incubation period 26 weeks. 15.8), can be given systemically as a mass
treatment on its own or is a side-benefit of
Period of communicability As long as there one of these control programmes. If none of
are viable mites on the individual, up until the special preparations are available, then
1 week after the first course of treatment. repeated applications of oil to the skin
can be effective. Any oil usually used by
people to rub on the skin, such as coconut
Occurrence and distribution Scabies is
oil, can be effective. As the mite lives in a
found worldwide, but favours the hot,
small burrow through which it breathes, to
moist tropics and flourishes in conditions
seal-off the opening with a film of oil as-
of poverty. It mainly occurs in children,
phyxiates it. This requires careful and
but anyone who comes in contact with
repeated application to the whole body
infected individuals (e.g. mothers and
after washing.
school teachers) can become infected with
scabies. Surveillance School teachers should be
encouraged to regularly examine school
Control and prevention Scabies is a commu- children or do spot checks on any child
nity problem and treatment of an individual found to be scratching.
is insufficient unless the whole family,
school or village is similarly treated. In com-
munities with poor hygiene, the provision of 7.2 Lice
adequate water is the most effective method
of controlling the disease. People should be Body lice are potential vectors of typhus
encouraged to wash themselves with soap (Section 16.2) and relapsing fever (Section
and water and wash their clothes and bed- 16.3), but the main worry of people is per-
ding. Improving the water supply to provide sonal infestation.
an adequate quantity of water is the main
method of prevention. Organism Pediculus humanus corporis, the
body louse, P. h. capitis, the head louse and
Treatment Specific treatment is by benzyl P. thirus pubis, the crab louse. Lice glue
benzoate, but this may need to be accompan- their eggs to body hairs (nits) in which they
ied by an antibiotic if there is secondary are resistant to treatment until the nymphs
infection. A 10% emulsion of benzyl benzo- hatch.
ate is liberally applied to the whole body
and left for 24 h before being washed off. Clinical features and diagnosis Intense, local-
Treatment is repeated after 7 days to kill off ized itching at the site of bite will indicate
larvae that have hatched from eggs. The lice, which can be found and identified with
whole family is treated at the same time, a hand lens. If P. h. corporis is not on the
ensuring that only clean clothes and bed- skin, they will be amongst body hair or in
ding are used. Alternatively crotamiton the clothes.
10% or sulphur 6% in petrolatum is applied
to the entire body for 23 days before being Transmission is by close contact between
washed off. The insecticide permethrin, people, the sharing of clothes, hats and
82 Chapter 7
combs. Crab lice are generally transmitted be scratching his/her head. In situations
during sexual contact. such as refugee camps, people should be
encouraged to examine their clothes and
Occurrence and distribution Body lice are those of their children at regular intervals.
found worldwide in conditions of poverty
or where people are forcibly driven together,
such as in refugee camps. They are more 7.3 Superficial Fungal Infections
common in colder regions of the world or (Dermatophytosis)
in mountainous parts of the tropics where
people huddle together to keep warm. Head Organism Fungi of the genus Trichophyton,
lice are found both in the tropics and the Microsporum, Epidermophyton and Scytali-
colder regions, especially amongst school dium.
children.
Clinical features Also called tinea, the
Incubation period Eggs hatch in 1014 days. fungi attack specific sites on the body,
the moist skin in the feet or groin, the nails,
the scalp or the body. Tinea corporis (often
Period of communicability is as long as there
called ring worm) produces well-defined,
are viable lice on the individual, up until 2
circular lesions that spread out from the
weeks after the first course of treatment.
centre causing slight depigmentation as
Body and head lice remain alive for up to
they proceed. Tinea capitis causes areas
1 week on clothing not being worn, and nits
of baldness, hairs becoming brittle so that
for 1 month.
they break off. Tinea versicolor produces
a blotchy hypopigmentation that can
Control and prevention Washing with warm sometimes be misdiagnosed as leprosy.
water and soap at frequent intervals is the Tinea imbricata is particularly common in
main method of prevention. Clothes of an Western Pacific Islands, producing serpigin-
infected person should be boiled or insuf- ous scaly designs that can cover the whole
flated with insecticide powder. The practice body.
of pressing clothes with a hot iron might
have originated as a method of controlling Diagnosis is clinical, but infected hairs
lice. Combs should be washed regularly and fluoresce in ultraviolet light.
only used by one person.
Transmission is by close bodily contact, the
Treatment is with 1% permethrin cream sharing of clothes, towels, etc. Dogs, cats
rinse, naturally occurring pyrethrins (from and other animals also carry the fungus.
Chrysanthemum) and oral ivermectin. The
treatment should be repeated after 1014 Incubation period 414 days.
days to kill any young lice recently hatched
from nits. Shaving of heads is a rigorous and Period of communicability Fungal material
effective method of control of head lice, but can persist on articles, such as towels
not of body lice. In epidemic situations, and clothing, for considerable periods of
whole communities should be treated irre- time.
spective of whether lice have been found or
not (Section 16.2). Clothes and bedding can Occurrence and distribution Superficial
be treated with 1% malathion, 0.5% per- fungal infections are widely distributed
methrin, 2% temefos (Abate), 5% iodofen- throughout the world, being found in
phos, 1% propoxur or 5% carbaryl. developed as well as developing countries.
Children are most commonly affected.
Surveillance Parents or older siblings
should carefully search through childrens Control and prevention Prevention is by
hair, looking for nits, if the child is found to washing the body with soap and water, and
not sharing clothes, towels, combs, etc. fever. An ulcer that refuses to heal then de-
Towels should be boiled. velops at the initial point of infection, pro-
ducing increasing tissue loss.
Treatment Local applications, such as
tolnaftate, miconazole, ketoconazole, clotri- Incubation period Uncertain but probably
mazole, econazole, naftifine, terbinafine or between 1 and 5 days.
ciclopirox, can be used. Acetylsalicylic acid
ointment or benzoic acid compound (Whit- Period of communicability Unknown, but
fieldss ointment) are effective if applied probably as long as there are moist lesions.
regularly for nearly 3 weeks. In resistant
cases, griseofulvin, itraconazole or oral ter- Occurrence and distribution Tropical ulcers
binafine can be given by mouth for a suffi- are found in the warm, moist areas of the
ciently long period to clear all the fungal world, where the temperature and humidity
residue. are fairly constant. All ages and both sexes
are susceptible.
Surveillance School children should be
examined regularly, especially the head, Control and prevention Tropical ulcers can
feet and groins. be prevented by taking scrupulous care over
minor cuts and abrasions. As soon as any
break in the skin surface occurs, it should
7.4 Tropical Ulcers be cleaned, an antiseptic applied and
covered with a dressing. Where dressings
Tropical ulcers are a common debilitating are in short supply, certain kinds of leaves
condition. They cause tissue loss and pain, can be used. Flies should be controlled by
which temporarily invalids the person, the provision of sanitation (Section 3.3.4)
making daily work an agonizing burden. and the disposal of garbage.
The condition can last for several months
and even when it heals, the victim is left Treatment During the invasive stage, antibi-
with a scar that may lead to contracture. otics should be given both systemically and
There are two types of tropical ulcers: non- locally, and the limb rested. Once the ulcer
specific or due to a Mycobacterium, often has formed, antibiotics have no effect and a
called Buruli ulcer. These should both be cleaning solution, such as Eusol, should be
differentiated from yaws (Section 14.1). applied. In coastal areas, soaking the
affected limb in seawater is a cost-free
method of cleaning out the ulcer. Skin
7.4.1 Non-specific tropical ulcers grafting may be necessary.
Organism No specific organism is normally

detected, but initial infection is often ac- 7.4.2 Buruli ulcer
companied by cellulitis, probably caused
by a Streptococcus. Organism Mycobacterium ulcerans is found
in the exudate of the ulcer.
Transmission Flies are responsible for con-
taminating small wounds and scratches or Clinical features There is at first just a small
occasionally biting insects transmit papule surrounded by shiny skin, but this
infecting organisms directly. Scratching of soon breaks down to reveal a large necrotic
the wound by the host can be a potent ulcer with undermined edges. Tissue
method of instilling organisms into the skin. damage may be extensive involving bone
and other structures.
Clinical features The initial wound becomes
red and indurated, with cellulitis spreading Diagnosis is made on clinical grounds and a
to the regional lymph nodes, and systemic stained smear of the exudate.
84 Chapter 7
Transmission The method of transmission Clinical features Commencing as a kerato-

has not been elucidated, but there are conjunctivitis, the first sign is red eye.
presumed to be environmental factors due There may be irritation and discharge, but
to the relationship with rivers and wetlands. it is passed off as a self-limiting infection. A
The role of aquatic insects has recently been follicular infiltration of the conjunctiva then
suggested as M. ulcerans has been found in takes place particularly in the upper lid.
the salivary glands of insects. Focal out- Blood vessels grow into the periphery of
breaks have followed migrations and move- the eye, forming pannus. Trachoma is often
ments of people, for example due to floods or complicated by secondary infection. It is at
dam construction. In Australia, koalas and the late stages of the disease, when it is non-
opossums are found naturally infected. infectious that scarring, particularly of the
upper eyelid, turns the eyelashes inwards to
Incubation period Unknown. rub on the eye, a condition called trichiasis.
This constant rubbing of the eyeball, aided
by the dryness of the conjunctiva, damages
Occurrence and distribution Central Africa, the cornea, leading to scarring and finally
Central and South America, Southeast Asia, blindness.
Australia and New Guinea. Children and
women living near rivers or wetlands in a
Diagnosis is usually made on clinical
rural region are predominantly affected.
grounds, but can be confirmed by finding
There has been a progressive increase in
the characteristic inclusion bodies in
cases and more attention is being paid to
scrapings taken from the conjunctiva.
working out the transmission and how to
control the infection.
Transmission Trachoma is a disease of poor
sanitary conditions where a combination of
Control and prevention Several trials have
close contact and dirty conditions encour-
been made with BCG vaccination
ages transmission. Within the family unit,
and although these showed some early
transmission is from child-to-child or by
protection, it was not sustained. Health
flies that are attracted to the discharges
education in areas of high endemicity, with
around the eyes. These are mainly Musca
the provision of facilities for treating lesions
sorbens. Cycles of reinfection and recrudes-
as soon as they occur, has reduced the
cence continue to damage the eye and lead
period of debility and the severity of the
to blindness at school age. The usual
deformities.
method of wiping away secretions with
hands, towels or clothing, which is then
Treatment Anti-mycobacterial drugs, such used by the adult on other children or
as streptomycin, dapsone, rifampicin or themselves, is a typical pattern of transmis-
thiambutosine, have been found to be help- sion.
ful, especially in the early stage, but essen-
tially treatment is surgical with excision of
Incubation period. 512 days.
the ulcer and skin grafting.
Period of communicability continues as long

as active lesions are still present. Once treat-
7.5 Trachoma ment commences, infectivity ceases within
23 days although the clinical disease per-
A common infectious disease, trachoma is sists.
the major cause of blindness in the world.
Occurrence and distribution Trachoma is
Organism Chlamydia trachomatis, a micro- found mainly in the dry regions of the
organism that has features both of bacteria world (Fig. 7.1), especially Africa, South
and viruses. America and the extensive semi-desert
Fig. 7.1. The distribution of trachoma.
86 Chapter 7
regions of Asia. A disease of antiquity, it was Treatment Mass treatment is preferable, as

first described by the ancient Egyptians. the majority of the population in an infected
In endemic areas, 8090% of children area will have trachoma. This is given easily
are infected by the age of 3 years. In condi- in schools, but is better done at home, where
tions of improved sanitation, there is a nat- the main transmission takes place. A single
ural cycle lasting until the age of 11 years, dose of azithromycin (20 mg/kg) is better
with little residual damage. Females de- than topical tetracycline and one dose a
velop trachoma and blindness as adults year may be sufficient to eliminate the
more commonly than males because they blinding propensity of trachoma. Mothers
are directly concerned with looking after can be taught to regularly treat all children
children. The chance of acquiring infection in the household.
is increased by large families with short Preventing blindness, once scarring and
birth intervals, as there are more children trichiasis have developed, is very easily
of a young age living in close proximity. done by a simple operation that a Medical
Assistant can be trained to do. This involves
Control and prevention The use of water to cutting through the scarred conjunctiva of
wash away secretions, clean clothes and the the upper lid and everting it so that the eye-
surroundings is perhaps the single most ef- lashes no longer rub on the cornea.
fective method. Washing the face often has
been shown to reduce the risk of developing Surveillance After the initial survey, follow-
trachoma so regular daily face washing up surveys should be conducted at regular
should be encouraged. Long-term prevent- intervals. This is most easily done in pri-
ive measures include improved sanitation mary schools.
and the provision of water supplies.
Flies proliferate in rubbish and excre-
ment, reaching their maximum numbers 7.6 Epidemic Haemorrhagic
during the dry, sunny period of the year.
Conjunctivitis
The damp, moist conditions in open pit
latrines may be more important in encour-
aging fly breeding than non-use of latrines. First recognized in Ghana in 1969, epidemic
Any flushing mechanism or improved acute haemorrhagic conjunctivitis has
latrine will discourage flies. caused epidemics in a number of parts of
A strategy for a control programme is as the world, which have given their name to
follows: the disease (e.g. Nairobi eye).
. conduct a survey to find the worst- Organism Enterovirus 70 is the most import-
affected areas; ant aetiological agent and has been respon-
. give mass treatment; sible for tens of millions of cases.
. conduct health education through Coxsackievirus A24 has also been respon-
schools, stressing regular face washing; sible for large outbreaks.
. provide back-up services.
Clinical features The infection starts sud-
WHO has launched a programme for the denly, with pain and sub-conjunctival
global elimination of trachoma by 2020 and haemorrhages. There is often much swelling
given it the acronym of SAFE. This stands and discomfort in the eye; however, it is a
for: self-limiting condition, terminating within
12 weeks. In a few cases, there are systemic
. Surgery for trichiasis; effects involving the upper respiratory tract
. Antibiotics; or central nervous system (CNS). CNS
. Facial cleanliness; effects are identical to those of poliomyelitis
. Environmental improvement. and residual paralysis can occur.
Diagnosis is clinical once the first few cases ring. Upper respiratory symptoms and fever
of an epidemic have been identified. Labora- often accompany the eye disease.
tory confirmation can be made by isolating
the virus from a conjunctival swab. Transmission Similar to epidemic haemor-
rhagic conjunctivitis.
Transmission is from one person to another
from the discharges of infected eyes. Where Incubation period 412 days.
there are systemic infections, transmission
may be by the respiratory route. As with Period of communicability 14 days from
trachoma, intra-familial transmission is onset of disease.
common and in situations of poor hygiene
and overcrowding, large epidemics can Occurrence and distribution Epidemics have
occur. occurred in Asia, North America and
Europe.
Incubation period 13 days.
Control and prevention are similar to epi-
Period of communicability 4 days from the
demic haemorrhagic conjunctivitis.
start of symptoms.
Occurrence and distribution It occurs in epi- Treatment and surveillance As with haemor-
demic form infecting a large number of rhagic conjunctivitis.
people in the immediate vicinity. Epidemics
have been mainly in tropical cities in Africa,
Asia, South America, the Caribbean and Pa- 7.7 Ophthalmia Neonatorum
cific Islands.
Infection of the eye of the newborn infant
Control and prevention Careful hand-wash- can lead to blindness.
ing, use of separate towels and sterilization
of ophthalmologic instruments are import- Organism Neisseria gonorrhoea or C.
ant in preventing transmission. Methods to trachomatis.
improve hygiene and reduce overcrowding
will prevent major epidemics.
Clinical features and transmission If the
mother has gonorrhoea or non-gonococcal
Treatment There is no treatment, so
urethritis (NGU) caused by C. trachomatis
mass administration of eye ointment is not
(see Sections 14.5 and 14.6), the infants
applicable.
eyes can become contaminated with infec-
tious discharges as it passes through the
Surveillance The first cases of an epidemic
birth canal. This leads to conjunctivitis and
should be notified centrally and neighbour-
in gonococcal infection, an important cause
ing countries warned.
of blindness, especially in developing
countries.
7.6.1 Epidemic keratoconjunctivitis
Diagnosis is made by microscopic examin-
Organism Adenovirus 5, 8 and 19. ation of maternal vaginal discharges.
Clinical features Epidemic keratoconjuncti- Incubation period is 15 days in gonococcal

vitis is similar to epidemic haemorrhagic infection and 512 days with Chlamydia
conjunctivitis, but a keratitis also develops infection.
in some 50% of cases, 7 days after onset.
This normally resolves in about 2 weeks, Period of communicability As long as genital
but a minority is left with conjunctival scar- or ocular infection persists.
88 Chapter 7
Occurrence and distribution Infection is Surveillance. All vaginal discharges during

found more commonly in sex trade workers the antenatal period should be examined
and the sexually promiscuous. It is more and cultured. Where an infant is born with
common in developing countries, where ophthalmia neonatorum (sticky eye), the
routine testing of expectant mothers is not parents and any sexual contacts should be
performed. fully investigated (Section 14.5).
Control and prevention Detection and treat-

ment of the initial infection in the mother
(see Sections 14.5 and 14.6) is the best strat-
egy. Any vaginal discharge occurring during 7.8 Other Infections
pregnancy should be examined, cultured
and treated. Many of the faecaloral diseases covered in
Chapter 8 and those due to soil contact
Treatment At delivery, all babies eyes in Chapter 10 are due to poor personal hy-
should be routinely wiped and a 1% aque- giene. Streptococcal and staphylococcal
ous solution of silver nitrate instilled. infections of the skin (Section 12.6) are also
Wiping both eyes at delivery alone can prevented by good personal hygiene. Yaws
reduce the incidence of infection if silver (14.1), pinta (14.2) and endemic syphilis
nitrate is not available and should always (14.3) are readily cured by penicillin, but
be practised. A 2.5% solution of povidone- in the long-term, personal hygiene is the
iodine, tetracycline 1% or erythromycin best preventive strategy. A full list of dis-
0.5% eye ointment, can be used as alterna- eases prevented by good personal hygiene
tives to silver nitrate. can be found in Section 3.3.1.
8
FaecalOral Diseases
The faecaloral group of diseases is trans- Clinical features Profuse, watery diarrhoea
mitted by person-to-person contact, through with occasional vomiting, but despite the
water, food or directly to the mouth. The fluid nature of the stools, faecal material is
absence of a proper water supply, rubbish always present. There is never the rice-water
and dirty surroundings with an abundance stool characteristic of cholera. Water and
of flies are the typical situations in which electrolytes are lost, which in the young
these diseases thrive. The incidence of these child may be sufficient to cause dehydration
diseases can be controlled by: (i) breaking and ionic imbalance, leading to death. Nor-
the faecaloral cycle with personal hygiene; mally, a self-limiting condition, but in un-
(ii) increase in water quantity; (iii) improve- hygienic surroundings, or where babies
ment in water quality; (iv) food hygiene; and bottles are used, repeated infections occur
(v) the provision of sanitation. The disposal leading to chronic loss of nutrients and sub-
of garbage and the control of flies are also sequent malnutrition. A serious infection in
important. neonates, mortality decreases with age until
Many of the diseases in this group cause in adults, it is just a passing inconvenience
diarrhoea (Table 8.1). (travellers diarrhoea).
Diagnosis is made on clinical criteria unless

8.1 Gastroenteritis laboratory facilities sufficient to identify
viral infections are available. Specific DNA
Gastroenteritis is a common form of diar- probes are likely to be the most appropriate
rhoea that predominantly attacks children. method of identifying causative organisms
It is endemic in developing countries, but in developing countries if they can be made
seasonal epidemics occur. Attempts to find cheap enough.
a specific organism as a cause are often un-
successful and not essential, as management Transmission Epidemics occur in families or
and control are the same. Strains of entero- groups of children sharing similar surround-
toxigenic, enteropathogenic and enteroag- ings. Infection is often seasonal, for
gregative Escherichia coli as well as enteric example, the beginning of the rains
viruses, particularly rotavirus, are the main heralding an outbreak. This would suggest
organisms. Campylobacter (Section 9.2) is transmission by water and simple control
now a major cause. measures, such as boiling of water, can
89
90 Chapter 8
Table 8.1. Diarrhoeas.
Presentation Disease Organism Characteristics
Acute watery Salmonellosis, food Salmonella, Staphylococci, Sudden onset with vomiting in
diarrhoea poisoning B. cereus, C. perfringens, group of people associated by
V. parahaemolyticus food
Gastroenteritis E. coli or non-specific Common, mainly in children,
(bacterial) epidemic
Gastroenteritis Rotavirus and other Occurs in children, often in
(viral) enteroviruses institutions (hospitals, schools,
Cryptosporidiosis Cryptosporidium etc.)
Cholera V. cholerae Severe, dehydration, rice-water
stools, epidemic
Acute diarrhoea with Bacillary dysentery, Shigella sp., C. jejuni Severe, seasonal, all ages
blood Campylobacter Sporadic, from
contaminated food, animal
reservoir
Chronic diarrhoea Giardiasis G. intestinalis Mainly children and travellers
(Sprue or malabsorption syndromes) Adults, mostly males; nutritional
deficiencies especially of folic
acid
Chronic diarrhoea Amoebiasis E. histolytica Cooler climates, mainly adults
with blood
Balantidiasis B. coli Similar to amoebiasis;
associated with pigs
Schistosomiasis S. mansoni Endemic areas, characteristic
eggs in stools
B. (cereus), Bacillus; C. (perfringens), Clostridium; V. (parahaemolyticus), V. (cholerae) Vibrio; E. (coli), Escherichia;

C. (jejuni), Campylobacter; G. (lamblia), Giardia; E. (histolytica), Entamoeba; B. (coli), Balantidium; S. (mansoni),
Schistosoma. Many other diseases cause diarrhoea (e.g. measles, malaria, tonsillitis).
stop the epidemic. Improperly sterilized Control and prevention is by the following
babies bottles or their contents are a methods:
common method of infecting the neonate.
. promotion of breast-feeding;
Incubation period 1272 h (generally . use of oral rehydration solution (ORS) in
48 h). the community;
. improvement in water supply and sanita-
tion;
Period of communicability 810 days. . promoting personal and domestic hy-
giene;
Occurrence and distribution Gastro- . vaccination (rotavirus and other vaccines,
enteritis is found throughout the world, e.g. measles).
especially in developing countries and in
conditions of poor hygiene. It is particularly Breast-feeding not only provides a sterile
common where bottle-feeding has been re- milk formula in the correct proportions (in
cently introduced, such as by unscrupulous contrast to the often-contaminated bottle),
infant-feed companies. A seasonal distribu- but also promotes lactobacilli and contains
tion suggests contamination of the water lactoferrins and lysozymes. Promoting
supply. breast-feeding and the administration of
FaecalOral Diseases 91
ORS solution in the community are the main

control strategies. Improvement in water
supplies and sanitation, with the promotion
of personal hygiene, are long-term meas- One litre clean water
ures. +
The oral cholera vaccine WC/rBS has
been shown to be about 60% effective
against enterotoxigenic E. coli so might One level teaspoon salt
have some place in control although its pro- +
tective effect in infants is considerably less.
Rotavirus vaccine (RRV-TV) has so far been
shown to be less effective in developing
countries than the developed and several
cases of intussusception has resulted in its
withdrawal from use in the latter. Prevent-
ing other childhood infections by vaccin-
ation, especially those associated with
gastro-intestinal disease, such as polio and
measles, can reduce the severity of gastro-
enteritis.
Treatment is by replacement of fluid and 8 level teaspoons sugar

electrolytes using ORS in the moderately +
dehydrated and intravenous replacement
in the severely dehydrated.
A suitable ORS is made by dissolving the following

constituents in 1 l of water:
The juice of one orange (for potassium)
Sodium chloride 3.5 g (Na 90 mmol)
(salt)
Fig. 8.1. Preparing a simple oral rehydration
Trisodium citrate 2.9 g (citrate 10 mmol)
solution.
dihydrate
Potassium chloride 1.5 g (K 20 mmol, Cl tering it to her child. If it tastes salty, then
88 mmol)
more water should be added.
Glucose anhydrous 20.0 g (glucose 111 mmol)
(dextrose)
A naturally available rehydration solu-
tion is the fluid from a green coconut. A
7-month coconut has been found to be the
These ingredients can be obtained sep- most suitable. Rice-water made from a hand-
arately or in packets of readily prepared ful of rice boiled in a saucepan of water until
mixtures. In the absence of prepared it disappears, plus the appropriate amount
packets, a simpler formulation can be made of salt for the volume of water, makes a
as shown in Fig. 8.1, which consists of simple rehydration solution. Carrot water
mixing salt and sugar in 1 l of clean water. can also be used.
Potassium is not an essential constituent, If mothers are taught how to make up
but addition of the juice of one orange is these solutions, then they can treat their
useful. Tea leaves also contain potassium, children as soon as they start to get diar-
so the mixture can be prepared as tea with rhoea. The mother should use a cup and a
the addition of salt and sugar. Teaspoons spoon and sit with her child giving it small
vary in size and it is dangerous to give too quantities of fluid at frequent intervals.
much salt; hence a useful check is for the Severe dehydration can usually be pre-
mother to taste the solution before adminis- vented by primary care from the mother.
92 Chapter 8
There is no need to use an antibiotic or Occurrence and distribution. Cryptospori-

an antispasmodic, both of which are contra- diosis has a worldwide distribution, found
indicated. Lactobacilli, which inhibit E. particularly in conditions of poor hygiene. It
coli, colonize the gut in the breast-fed infant. is endemic in many developing countries
In some countries, lactobacilli are adminis- where infection is acquired at an early age.
tered in yoghurt (curd). Massive epidemics have occurred in de-
veloped countries when the water purifica-
Surveillance In countries with a seasonal tion system had failed (such as the 1993
rainfall pattern, gastro-enteritis outbreaks Milwaukee epidemic where there were
often start with the beginning of the rains, 500,000 cases). In other areas, it is a disease
so monitoring the weather can provide early of animal handlers, homosexuals and insti-
warning of an impending outbreak. tutions. There is a marked seasonality in the
northern hemisphere with peaks of disease
in spring and autumn.
8.2 Cryptosporidiosis
Control and prevention is by personal hy-
Organism Cryptosporidium parvum is a giene, the provision of sanitation and safe
protozoan parasite found in poultry, fish, water supplies. Domestic animals and pets
reptiles and mammals, especially cattle, can be important sources of infection and
pigs, sheep, dogs and cats, from which the therefore precautions should be taken
infection can be acquired. when handling them.
Clinical features Cryptosporidiosis pre- Treatment is with oral rehydration to re-

sents as an acute watery diarrhoea associ- place fluid loss (Section 8.1).
ated with abdominal pain. Fever, anorexia,
nausea and vomiting can also occur, espe- Surveillance Animals, particularly cattle
cially in children. There may be repeat and pigs, can be examined for Cryptosporid-
attacks, but these do not normally continue ium infection.
for more than a month. In the immunodefi-
cient, especially those with HIV infection,
the disease enters a chronic and progressive 8.3 Cholera
course.
Organism. Vibrio cholerae. Classical chol-
Diagnosis is by finding the oocyst in faecal era is caused by V. cholerae 01, while most
samples. Alternatively, the intestinal stages of the recent epidemics have been due to the
can be looked for in intestinal biopsy speci- El Tor biotype. V. cholerae 0139, which
mens. appeared in 1992, is a more virulent ser-
ogroup variant of the El Tor biotype.
Transmission is from person-to-person
via the faecaloral route, from animals or Clinical features A profound diarrhoea of
faecal-contaminated water. The oocyst rapid onset that leads to dehydration and
can survive in nature for a considerable death should be considered as a case of chol-
period of time. The infecting dose is very era until proved otherwise. The diarrhoea
low. contains no faecal particles, but is watery
and flecked with mucus (not cells), the so-
Incubation period. 112 days. Mean of called rice-water stools. The passage of large
7 days. quantities of fluid leads to rapid and ex-
treme dehydration, which can be fatal.
Period of communicability Up to 6 months in Vomiting can also be present in the early
faecal material. stages.
Diagnosis V. cholerae can be identified from epidemiological investigations show this

the diarrhoeal discharge, vomitus or by source of infection to be important, but
rectal swab. Its characteristic mobility (it bacteriologists have not isolated organisms
vibrates, hence being called a vibrio) can be in sufficient numbers. One possible explan-
seen by dark ground or phase-contrast mi- ation is the presence of non-agglutinable
croscopy and is inhibited by specific anti- vibrios (alternatively known as non-cholera
serum. Confirmation of the diagnosis is vibrios), which are closely related to V.
made by culture on TCBS sucrose agar. cholerae except that they do not agglutinate
A suitable transport medium is Carey Blair, antisera. These are known to be mutations
or alternatively 1% alkaline (pH 8.5) pep- so that shifts between typical vibrios and
tone water, which can also be used for non-agglutinable forms may occur. If this
water samples. is a regular feature in nature, then it could
help to explain where cholera goes to
Transmission Classical cholera is a disease (especially the classical form) during inter-
of water transmission, whereas El Tor is by epidemic periods. The appearance of
both water and food. Generally, epidemic non-01 cholera (vibrio 0139) supports this
cholera is transmitted by water and endemic view.
cholera by food. It may appear in a seasonal V. cholerae has been found to remain
pattern, often in association with other viable in crude sewage for over a month
causes of diarrhoea (Fig. 8.2). It is the en- and in sewage-contaminated soil for up
demic nature of El Tor and its persistence to 10 days, a possible source of infection
in the environment that has been respon- carried over to rivers or wells. It has
sible for its prodigious spread. been isolated from a number of foodstuffs
For every clinical case of El Tor cholera, especially those with a pH between 6 and
there can be as many as 100 asymptomatic 8, such as milk produce (e.g. ice cream),
cases, explaining how epidemics spread sugar solutions, meat extracts or articles
from one region to another, but not how of food preserved by salt. Uncooked fish
infection persists in the environment. Vib- and vegetables, which have been washed
rios may be able to persist in an aquatic or irrigated by sewage effluent, have been
environment, such as in the mucilaginous responsible for outbreaks.
covering of water plants or fish, in associ- Direct person-to-person spread or via
ation with copepods or other zooplankton. fomites, such as utensils or drinking straws
An alternative method may be due to con- (in home-brewed alcohol parties), do not
tinuous person-to-person transmission in appear to be as important as expected.
a sub-clinical asymptomatic cycle. When a Even for persons attending the death of a
susceptible person enters the cycle or there cholera victim, it is more likely that infec-
is an environmental or climatic change, a tion will result from drinking water or con-
fresh epidemic starts. suming food that has been prepared for the
V. cholerae in water are easily des- mourning ceremony, rather than from the
troyed by sunlight, chemical action or com- dead person or their shrouds.
peting bacteria. However, where these A case of cholera can excrete between
elements are not present, it can survive in 107 and 109 V. cholerae per millilitre
fresh water for some time and in saline water of diarrhoeal discharge and since the
for at least a week. The level of salinity volume of this discharge may be in
needs to be between 0.01% and 0.1% as is excess of 20 l/day, the potential for contam-
found in estuarine or lagoon water. V. cho- ination of the environment is enormous.
lerae in these saline environments can be Clearly, though the severe case is unlikely
taken up by shellfish or fish, which then to be anything but a transitory source,
form an alternative method of infection it is the asymptomatic case passing from
when eaten uncooked. 102 to 105 organisms/g of stool in a spas-
The isolation of V. cholerae from modic manner that poses the greatest
river water has been perplexing because hazard.
94 Chapter 8
2500
Gastroenteritis
Cholera
2000
1500
Cases
1000
500
0
J FMAM J J A SOND J FMAM J J A SOND J FMAM J J A SOND
1973 1974 1975
1500
1000
Cases
500
0
J FMAM J J A SOND J F M A M J J A S O ND J FMAM J J A SOND
1976 1977 1978
Fig. 8.2. Similar pattern of gastroenteritis and cholera in Calcutta, India (19731978). (Reproduced with
permission from the Indian Council of Medical Research (1978) National Institute of Cholera and Enteric
Diseases, Annual Report, Indian Council of Medical Research, Calcutta.)
A high dose of V. cholerae is required press gastric acidity. Blood group O is

to infect the healthy subject. Some 106108 associated with an increased severity of
organisms are needed, but if the person has a cholera.
decreased gastric acidity, then 103 organ-
isms may be sufficient. Lowered gastric
acidity is found more commonly than Carriers are of short duration; 70% of
expected and may be related to malnutrition cholera cases are free of vibrios at the end
or diet. Cannabis smoking is known to de- of the first week and 98% by the end of the
third. Long-term carriers are rare and of no ized by super-chlorination (adding two to
epidemiological importance. three times the calculated amount of chlor-
ine required for the volume of water) or
Incubation period 15 days. people should be advised to boil the water
they use for drinking. Boiling water is un-
popular as it uses vital firewood, monopol-
Period of communicability is until about
izes scarce cooking pots and the water has a
5 days after recovery, but prolonged excre-
flat taste. However, there is no reason why
tion of organisms can continue in some in-
water cannot be boiled at the same time as
dividuals. Antibiotics reduce the period of
the meal is cooked and simple clay pots
communicability.
used instead of metal ones. Boiled water
can be re-aerated by shaking it up. A not so
Occurrence and distribution Humans are the safe, but easier method is to leave water to
only known reservoir, but the persistence of stand and then decant off the supernatant.
the organism in the environment, in pos- A simple way of doing this is the three-pot
sibly a changing form, as discussed above, system (Fig. 3.7). Chlorine can be added to a
may be another source. In endemic areas, well or community water supply, but any
cholera is a disease of children (adults vegetable matter in the water will inactivate
having developed immunity in childhood), chlorine and several times the amount cal-
whereas in its epidemic form, adults are the culated may be required.
more usual victims. The disease is associ- The banning or restriction of food
ated with poverty and poor hygienic prac- should only be made on good epidemi-
tices. ological evidence. If fish are properly
Classical cholera is restricted to South cooked before being eaten, then they are un-
Asia and caused by V. cholerae 01. The El likely to be a source. Disruption of a fish-
Tor biotype has infected Asia, Africa, eating practice may have dire consequences
Europe, Pacific Islands and South America; on other aspects of peoples health. It is
the majority of cases are now found in Africa. more often the fisherman rather than the
First isolated from pilgrims to Mecca in the fish, or the farmers, rather than their pro-
quarantine station of El Tor in West Sinai duce that are the purveyors of cholera.
(now Egypt) in 1906, it differs from the clas- Quarantine is rarely effective, as bribery
sical variety by producing a soluble haemo- or evasion of the barricades by the few who
lysin. It is classified as either Ogawa, Inaba or might be carrying the infection negates the
Hikojima of the classical serotypes. The im- hardships borne by the many who are not.
portance of the El Tor biotype is that it can Giving tetracycline to immediate contacts of
survive longer in water, is more infectious, cases will reduce the number of asymptom-
can cause mild infections and more fre- atic carriers, but the widespread distribu-
quently produces the carrier state. All these tion of the drug will encourage tetracycline
characteristics have assisted in the extensive resistance.
spread of this organism. The new and more The original inactivated V. cholerae
virulent V. cholerae 0139 has spread to many vaccination gives about 50% protection
parts of Asia and been responsible for epi- and only lasts for 6 months. It does not pre-
demics in India, Bangladesh, Myanmar, vent the asymptomatic disease state and can
Thailand and Malaysia. actively encourage the spread of infection
and, therefore, is not recommended as a
Control and prevention Control is aimed at method of control. A new oral vaccine
the cause. All too often a panic situation (WC/rBS) consisting of killed whole V. cho-
develops, foods are banned, vaccination lerae 01 in combination with a recombinant
given and quarantine instigated. If cholera B subunit of cholera toxin confers protection
is epidemic and preliminary investigations of up to 90% for 6 months and has been
indicate that water is the vehicle of trans- found to be effective in preventing cholera
mission, then the supply should be steril- in high-risk areas, such as refugee camps
96 Chapter 8
and urban slums. Protection was found to of normal saline and one unit of sodium
last for 3 years in 50% of those vaccinated bicarbonate can be used. The patient should
at the age of 5 years or above. Another oral be rehydrated intravenously as rapidly
vaccine (CVD 103-HgR) conferred good pro- as possible, the rehydration substituted
tection and was also effective in infants as by ORS once the patient can swallow. This
young as 3 months of age. Either of these allows the body mechanisms to regulate
vaccines can be used pre-emptively in electrolytes, as ionic imbalance can rapidly
high-risk areas, epidemic situations and occur with intravenous infusion to which
to protect travellers entering areas of high many patients succumb. The body fluid
endemicity. deficit should be restored, followed by
Persons dying from cholera should maintenance of one and a half times the
be buried quickly and the ceremony kept equivalent amount of bowel loss. Fluid loss
to a minimum. Disinfectants and hand- can be measured by directing fluid into a
washing facilities should be provided at bucket placed under the bed. A bed
treatment centres and when bodies are pre- or cholera cot is not essential though and
pared for burial. Flies should be controlled the patient can be nursed on a plastic sheet
by disposing or covering all faecal dis- laid on the ground with the earth hollowed
charges, although they have not been out under the pelvis to take a receptacle
shown to play a significant role in transmis- to collect the outpouring fluid.
sion. Tetracycline is not essential in treat-
ment, but shortens the duration of the ill-
Treatment The vibrio binds to the cells and ness and quantity of fluid replacement
produces an enterotoxin, which activates required. Tetracycline is given in a dose of
adenyl cyclase, an intracellular enzyme 500 mg 6-hourly for 3 days or Doxycycline in
that initiates a system of fluid and ion trans- a single dose of 300 mg. Sensitivity must be
port from the plasma to the intestinal lumen. monitored as the development of tetracyc-
There is no mucosal damage and increased line resistance will necessitate changing to
permeability is unlikely, which explains another antibiotic.
why glucose and electrolytes can still be The management of a cholera epidemic
absorbed by the mucosa. This allows large requires speed and good organization. Es-
quantities of low-protein fluid, bicarbonate sentially treatment is taken to the people by
and potassium to escape through an essen- setting up treatment centres at strategic
tially undamaged intestine. Management is places in the vicinity of the epidemic.
to correct dehydration in this otherwise self- These can be dispensaries, schools, church
limiting disease. halls or even tents, supplied with staff and
Fluid replacement must be rapid and fluids. Cholera patients do not need to be
adequate, the most easily available being treated in hospital.
the first choice. If rehydration can be started
as soon as cholera symptoms begin, then
oral rehydration will be all that is required. Surveillance for cholera is both national and
ORSs can either be prepared from ready international. An outbreak of cholera must
mixed packets of salts (Section 8.1) or by be reported to WHO, providing an advance
making a sugarsalt solution (Fig. 8.1). Un- warning system to neighbouring countries.
fortunately, most cases have already lost Nationally, a warning system can be imple-
a considerable quantity of body fluid on mented for diarrhoeal diseases where an in-
presentation, which means that they will crease in numbers or persons dying from
require intravenous infusion. If available, diarrhoea may indicate an underlying out-
Ringer lactate solution (Hartmanns) con- break of cholera (Fig. 8.2). Where cholera
tains the nearest approximation of electro- exhibits a seasonal pattern, the population
lytes to that lost in the diarrhoeal fluid. As and health staff can be placed on the alert
a second best option, a mixture of two units when the next season starts.
8.4 Bacillary Dysentery (Shigellosis) sive fly breeding takes place. Only 10100
organisms are required to produce the dis-
Organism Bacillary dysentery is due to Shi- ease.
gella invading the bowel. The species and Carriers can be important and
strains of Shigella are numerous. There are sporadic epidemics in institutions might in-
four main groups: dicate a food handler with unsanitary
habits.
. S. dysenteriae with 12 serotypes;
. S. flexneri with 14 serotypes; Incubation period 17 days.
. S. boydi with 18 serotypes;
. S. sonnei with one serotype. Period of communicability 4 weeks, but may
persist for longer in the carrier.
The most severe are S. dysenteriae and
the least severe S. sonnei, with S. flexneri Occurrence and distribution Any outbreak
being the most common in endemic areas. of an acute diarrhoeal disease with blood
Another form of bloody diarrhoea is due to should be considered to be bacillary dysen-
enteroinvasive and enterohaemorrhagic tery until proved otherwise. Distribution is
E. coli, particularly serotype 0157. worldwide with sporadic outbreaks occur-
ring in both the developed and the develop-
Clinical features Bacillary dysentery pre- ing world. Infection is often carried from one
sents as an acute diarrhoeal illness with area to another or across international
blood in the stools, more acute and severe boundaries by carriers.
than amoebic dysentery. In mild infections,
blood may be absent with a similar presen- Control and prevention Bacillary dysentery
tation to gastroenteritis. In severe cases, the is likely to present as an outbreak;
stools are a mixture of pus and blood, and so control will need to be implemented in
tenesmus is common. Fever accompanies the manner described in Section 4.1. Gener-
the illness and nausea or frank vomiting ally, it is better to bring treatment to the
can occur. Severity is determined by the site of the outbreak, setting up temporary
strain of organism and age of the person, treatment centres, unless the outbreak is a
with a moderate mortality in the very small one and the hospital has sufficient
young and very old. facilities to isolate cases. A seasonal out-
break will suggest that water supplies need
Diagnosis If bacteriological facilities per- to be improved. Search for carriers is gener-
mit, the organism should be identified, ally unsatisfactory and investigation should
typed and sensitivity determined. A suitable be restricted to food handlers.
transport medium is Carey Blair. Where Breast-feeding is protective for babies
this is not possible, a simple epidemi- and infants and should be continued even
ological investigation may provide suffi- by the sick mother. Washing hands with
cient information to indicate the mode of soap and water is the most effective method
transmission. of interrupting transmission.
With widespread antibiotic resistance,
Transmission is by the faecaloral route with Shigella infections could be controlled by
either food or water as the main vehicle vaccinating susceptible groups, especially
carrying the infection. Bacillary dysentery if there is an outbreak in the vicinity. A live
can occur in small outbreaks amongst fam- oral vaccine of S. flexneri (SC602) is cur-
ilies, suggesting food as the mode of transfer. rently under trial, while others are in the
Seasonal epidemics coinciding with the ar- developmental stage.
rival of the rains indicate water-borne
spread. Flies can be important in hot dry Treatment Management is the same as
months when garbage accumulates and mas- with other diarrhoeas to replace fluid and
98 Chapter 8
electrolytes lost. ORS is adequate and effect- for infecting people in restaurants, while a
ive in all cases, but the severely dehydrated poorly maintained water supply dissemin-
will require intravenous rehydration. There ates infection more widely. The cysts can
is a place for antibiotics in the treatment survive for several weeks in fresh water
of bacillary dysentery although sensitivity and are not killed by normal levels of chlor-
must be determined, as resistance is ine. An animal reservoir might also be re-
common. Ampicillin, nalidixic acid, sponsible.
TMPXSMX, ciprofloxacin or ofloxocin
can be given as a 5-day course. Antibiotic Incubation period 325 days; mean 7
treatment should not be relied upon as resist- 10 days.
ance makes control more difficult and the
disease can relentlessly spread though a Period of communicability The organism can
country. persist in the bowel for many months and
during all of this time the infection can be
Surveillance is similar to cholera (Section transmitted.
8.3) with notification of any outbreaks
and monitoring of the weather for seasonal Occurrence and distribution The infection is
occurrences. found worldwide, but is more common in
There are many similarities between the tropics and where conditions of hygiene
cholera and bacillary dysentery, especially are poor, ensnaring the unsuspecting travel-
in the management and control so further ler with chronic diarrhoea. Heavy infections
help can be found in Section 8.3. occur in children, especially those in insti-
tutions or debilitated by other conditions.
8.5 Giardia Control and prevention Individuals who are

rigorous with their personal hygiene can
Organism The small flagellate Giardia intes- largely avoid infection. Drinking water can
tinalis (lamblia) is a common commensal of be boiled or treated with five to ten drops of
the human small intestine, but heavy infec- iodine per litre of water. Proper food hand-
tions can cause diarrhoea. ling and preparation, especially the washing
of hands is essential, while long-term pre-
Clinical features Faeces are loose and greasy vention is through proper sewage disposal
with an unpleasant odour. Bloating and and the protection of water supplies.
abdominal distension can occur. Chronic
infections can produce partial villous atro- Treatment is with tinidazole either as a
phy with a resulting malabsorption syn- single dose of 2 g or 300 mg a day for 7 days.
drome. Giardia is one of the causes of Metronidazole can also be used.
travellers diarrhoea.
Surveillance Giardia is a common infection
Diagnosis The characteristic face-shaped in travellers and a routine stool examination
flagellate is occasionally seen in the faeces, after travelling to a less-developed area is
easily detected by its high motility, but the advisable.
cysts are more commonly found (Fig. 9.1).
Jejunal biopsy or the duodenal string test
may be performed in the differential diagno- 8.6 Amoebiasis
sis of the malabsorption syndrome.
Organism Amoebiasis is caused by the
Transmission is by person-to-person transfer protozoan Entamoeba histolytica, which
of cysts from the faeces of an infected indi- exists in an amoeboid form in the human
vidual or by contamination of food or water. large intestine and as a cyst in the environ-
Infected food handlers are often responsible ment.
The pathogenic amoeba enters a muco- sound. The abscess is usually not
sal fold and feeds on red blood cells tapped, unless in differential diagnosis
(RBCs). Penetrating through the muscularis from a bacterial abscess or is about to
mucosae, an abscess is formed with vascular burst.
necrosis taking place at its base. This leads
to tissue disintegration and the develop- Transmission Cysts of E. histolytica are
ment of an ulcer (the so-called flask-shaped formed in the large intestines and passed
ulcer). Active amoebae can be found in the into the environment in the faeces. They
base of an ulcer. survive in faeces for only a few days, but if
they enter water, they remain viable for con-
Clinical features Illness presents as acute siderably longer periods. Infection occurs
diarrhoea with frank blood, chronic diar- through drinking contaminated water or
rhoea or as an abscess with no apparent eating irrigated salad vegetables. Flies can
transitional period of diarrhoea. If the carry cysts for some 5 h. In circumstances
amoebic ulcer penetrates a blood vessel, of poor hygiene, direct faecaloral transfer
fresh blood is passed in the stool, which is via food, or by utensils, can take place.
a characteristic feature. Amoebae from the Cysts can survive in the cold for consid-
breached circulatory system are carried to erable periods, but they are killed by a tem-
various parts of the body, the liver being perature over 438C, which must be obtained
the commonest. In the liver, an abscess is in any composting system where human
formed, with the right lobe being the pre- faeces are used. Non-survival of amoebic
dominant site. Liver damage is a predispos- cysts is a useful indicator of effective decom-
ing cause with liver abscess more common position (see Fig. 1.2).
in males than females. The expanding ab-
scess can track outwards through the peri- Incubation period 24 weeks.
toneum, abdominal wall and on to the skin
or upwards to form a sub-phrenic abscess or Period of communicability Cyst passing can
enter the pleural cavity. The most serious continue for many years.
site of amoebic abscess development is in
the brain. All these features are illustrated
Occurrence and distribution Amoebiasis is
on Fig. 8.3.
a disease of poor hygiene, more commonly
Symptoms of an abscess are fever,
found in cooler environments than hot
weight loss and localized tenderness.
ones. In the tropics, it predominantly occurs
Amoebic pus is characteristically a pale red-
in highland areas or where there is a
dish brown colour (without odour) and
large temperature fluctuation. It is an infec-
can be discharged on to the skin from a
tion of adult life and if the period
penetrating ulcer, or coughed up from the
of residence in an endemic area is long,
lung. In a chronic infection, an amoeboma
there is greater chance of becoming
can be formed, which may be confused with
infected.
carcinoma.
Diagnosis is made by examining fresh Control and prevention is by personal

stool specimens within half an hour of hygiene, food hygiene and the proper provi-
their production for motile amoebae with sion of water and sanitation. Sand filtration,
ingested RBCs. Amoebae are occasionally especially if it is combined with alum floc-
found in amoebic pus, which similarly culation, removes cysts from water supplies.
must be examined as soon as possible as A high concentration of chlorine is required
the active forms rapidly die off. The finding to kill cysts (3.5 ppm residual) although they
of cysts indicates infection, but search are more sensitive to iodine.
must be made of fresh stool or pus for motile
amoebae. Liver abscess is diagnosed Treatment of all stages of the disease is by
by X-ray (raised diaphragm) or by ultra- metronidazole 2.4 g single dose for 3 days or
100 Chapter 8
Brain
Swallowed cyst
Lung develops into
trophozoite
Large
intestine
Liver
Skin
E.
histolytica
with engulfed red
blood cells
Amoebae in base of
ulcer entering
blood vessel
Non-pathogenic cysts in human intestine
Cyst passed
in stools
710 m 912 m 1520 m 1215 m

Endolimax lodamoeba Entamoeba coli E. histolytica
E. nana buetschlii
E. hartmani
Fig. 8.3. Amoebiasis.
2 g daily for 5 days or by other derivatives of

the 5-nitroimidazole group of compounds 8.7 Typhoid
(tinidazole, ornidazole and nimorazole).
Cyst passers can be given diloxanide furoate Organism Salmonella enterica serovar
(Furomate), 500 mg 8-hourly for 10 days. Typhi.
Surveillance Routine stool specimens Clinical features Although transmitted by

should be examined for amoebic cysts. the faecaloral route, typhoid manifests
Cysts of E. histolytica can be differentiated mainly as a systemic infection, generally
from other cysts by size and number of presenting as a fever. The fever starts grad-
nuclei (Fig. 8.3). ually, increasing in a stepwise fashion
over the first 12 weeks, with a progressive Transmission The main method of transmis-
malaise, disorientation and drowsiness. At sion is water, contaminated by faecal mater-
the end of the first week, a rash of character- ial from a carrier. These water-borne
istic rose spots may appear (not seen in black outbreaks may not always be explosive and
skins). where low-grade infection of the water
The stools are normally constipated at source is taking place, groups of cases,
first, but may later change to diarrhoea. If the spread over time, may occur.
organism localizes in the Peyers patches of S. enterica has been found to survive
the small intestine, ulceration, haemorrhage periods of 4 weeks in fresh water, but if
and perforation may occur. the water is stored in bright sunlight (as in
a reservoir), then the number of organisms
Diagnosis is difficult and depends upon rapidly dies off. It can survive in aerobic
finding the organism in blood, stool or conditions with organic nutrient present,
urine. A blood culture (35 ml) taken in the as found in contaminated streams. If
first week is the most satisfactory. Culture the stream is polluted with raw sewage,
from the stools can be obtained if repeated then the organism can survive over 5 weeks
examinations are made from the start of the and within solid faecal material for consid-
illness, with a greater likelihood of becom- erable periods of time. Seawater is bacteri-
ing positive as the illness progresses, pro- cidal, but where a sewage outfall is near
vided antibiotics have not been used. a shellfish bed, then the organism is
Finding the organism from urine, in which filtered and concentrated providing a potent
it is excreted spasmodically, is more diffi- source of infection if the shellfish are eaten
cult. Where the diagnosis has still not been raw.
made and further investigation considered Milk and dairy products provide ideal
necessary, S. enterica can be cultured from culture media and can become infected
the bone marrow or bile (by duodenal string during handling by a carrier, or rinsing of
test). Bone marrow culture has the advan- containers with polluted water. Contamin-
tage of occasionally being positive even if ated ice cream has been responsible for sev-
the patient has received antibiotics. Sewage eral outbreaks. Pasteurization of milk at
culture can be used in the investigation of 608C is effective in killing S. enterica. Infec-
epidemics. tion of meat products and canned foods is
The Widal test on the patients serum less common, but can occur in the cooling
can indicate infection, but a search for process (if carried out in polluted water).
S. enterica must also be made to confirm Flies can transmit the organism from
the diagnosis. The Widal test has three com- faeces to food, whereas person-to-person in-
ponents, the H (flagella) the O (somatic) and fection is uncommon. Secondary cases form
Vi antigens. The H antibody titre can be a very small proportion of an epidemic; so
raised by any Salmonella infection and serial transmission in an unhygienic envir-
remain raised (giving an estimate of previ- onment is not a feature.
ous exposure), whereas the O antibody indi-
cates recent infection. However, both H and Carriers The carrier state is the most
O levels will be raised by a recent typhoid important epidemiological feature, with
immunization, negating any value of the persistence of the organism in some individ-
test. A titre of 1/40 or higher is required. uals for periods in excess of 50 years. Three
Added weight is given to the diagnosis by per cent of typhoid cases are found to still be
making a series of tests and demonstrating a excreting organisms after 1 year. People
rising titre. The Vi antibody is produced become more prone to act as carriers if they
during the acute stage of the disease and have a chronic irritational process, such
persists while the organism is present as cholecystitis, and especially the presence
and, therefore, has a value in detecting the of gallstones (in which S. enterica are able
carrier state. to survive). Opisthorchis sinensis has
102 Chapter 8
also been associated with the development which outbreaks occur. Drinking water
of faecal carriers. Urinary carriers often taken from polluted streams can be boiled,
suffer from an abnormality of the urinary chlorinated or left to stand (the three-pot
tract such as calculus and Schistosoma hae- system in Fig. 3.7). Reservoirs and settling
matobium is a predisposing cause. tanks can reduce the level of organisms
below the infecting dose.
Incubation period is 330 days, with a mean Where the outbreak can be traced to
of 814 days. The length of the incubation a food source, a search for carriers can
period is inversely proportional to the be made. Stool specimens should be
infecting dose. obtained from persons involved in the prep-
aration of the food. If a carrier is discovered,
Period of communicability From 1 week after they should be prohibited from preparing
the start of illness for a period of 3 months, food. This cannot always be applied to do-
except in the chronic carrier where it con- mestic catering, so careful instruction in
tinues for years. personal hygiene should be tried. The organ-
ism can persist under the nails, so these
Occurrence and distribution In most tropical should be kept short. Food must be pro-
areas, the disease is endemic with seasonal tected from flies and stored only for limited
outbreaks. Water is probably the main periods. All shellfish must be properly
vehicle of transmission, but may be more cooked.
related to the gathering of people at scarce An infecting dose of at least 103 organ-
water sources (as occurs in the dry season), isms is required (except in persons suffering
rather than epidemics occurring with the from achlorhydria), but may need to be as
early rains. Endemic typhoid is maintained high as 109. The main effect of vaccination
by sub-clinical infections, especially in un- appears to be to offer protection against
diagnosed children, who obtain a degree of lower dose infecting inocula (less than 105
immunity. It has been suggested that these organisms).
sub-clinical infections result from persons Typhoid vaccine has a variable effect,
swallowing lower bacterial doses than the offering protection to persons who receive
critical threshold. In endemic areas, the a low infecting dose, but none to those who
peak of infection is in children between 5 ingest a high dose of organisms. It may,
and 12 years of age. therefore, be useful for individual protec-
Typhoid is a worldwide disease and tion, but is limited on a mass immunization
serious outbreaks, generally epidemic in basis, except to selected groups such as
nature, have occurred in developed coun- school children. The live oral vaccine (Ty
tries from contamination of the water supply 21a) gives protection for at least 3 years and
or food produce. Repair work on water sup- may also give cross-immunity against S.
plies or an accidental interruption of chlor- enterica Paratyphi B. It is administered in
ination has led to epidemics. Typhoid three capsules taken orally on days 1, 3 and
organisms have persisted in canned meat 5. A vaccine containing the polysaccharide
cooled in infected water thousands of miles Vi antigen is administered parenterally by a
away from the outbreak. Many well-known single injection. Both of these methods pro-
outbreaks have been due to ice cream. The duce less reaction than the whole-bacteria
movement of carriers can be followed from vaccine. A booster dose is required every
the outbreaks they produce as they travel 3 years in travellers or persons from non-
around. endemic areas living in countries where
typhoid is common. The oral vaccine is
Control and prevention Control relies on the probably more effective in young children
protection of water supplies and the sanitary and in mass programmes, given as a liquid
disposal of faeces. Placing latrines too close formulation rather than in capsules, but pro-
to wells, fractures in water mains and acci- guanil, mefloquine and antibiotics should
dental contamination by sewage are ways in be stopped 3 days before administration.
Treatment is with ampicillin or co-tri- and epidemic in developed, but is less com-
moxazole, but multiple resistant organisms monly detected.
have meant that more expensive antibiotics,
such as the quinalones (e.g. ciprofloxocin Control and prevention See typhoid.
and ofloxacin) and third-generation cepha-
losporins, are now required. Prolonged
Treatment See typhoid.
treatment of the carrier with ampicillin, 1 g
three times a day for 11 weeks has been suc-
cessful, or if available, one of the quinalones Surveillance See typhoid.
can be used. Relapse occurs in about 5% of
treated acute cases.
8.8 Hepatitis A (HAV)
Surveillance Once a carrier has been identi-
fied they should be warned of the danger Organism Infectious hepatitis is a viral in-
they pose to others and told to report their fection caused by a member of the Picorna-
condition to any medical people they come viridae, which includes both enteroviruses
in contact with. Carriers are sometimes and rhinoviruses.
registered by health authorities.
Clinical features The main pathology is in-
flammation, infiltration and necrosis of the
8.7.1 Paratyphoid liver, resulting in biliary stasis and jaundice.
The infection generally starts insidiously,
Organism Salmonella enterica Paratyphi A, the person feels lethargic, anorexic and
B and C. Paratyphi B is the commonest. depressed. Fever, vomiting, diarrhoea and
abdominal discomfort ensue before the ap-
Clinical features Paratyphoid is similar to pearance of jaundice reveals the diagnosis.
typhoid, but with less systemic effects and Once jaundice appears, the person generally
diarrhoea a more important feature. A rash is starts to feel better. Hepatitis A is a mild
less commonly seen, but when it does occur, disease leading to spontaneous cure in the
it is more extensive involving the limbs and large majority, with only a few cases de-
face as well as the body. Ulceration of the veloping acute fulminant hepatitis and
gut can occur, but less commonly than in even rarely severe chronic liver damage.
typhoid. There is an increase in symptomatic and
severe cases with increasing age.
Transmission Infection originates from a car-
rier or a person with the illness, more com- Diagnosis is made on clinical grounds and
monly food-borne than by other means (see by the demonstration of IgM antibodies to
under food poisoning, Section 9.1). HAV (IgM anti-HAV) in serum.
Diagnosis See typhoid. Transmission The early case is highly infec-

tious contaminating food and water.
Infection can also be transmitted directly
from poor personal hygiene such as by
hand-shaking. Intra-familial transmission
Period of communicability 12 weeks. is the commonest pattern generally due to
contamination of food and utensils by a food
Occurrence and distribution Paratyphoid handler, but large epidemics can occur
has a similar distribution to typhoid with where a person in the early stages of the
an endemic pattern in developing countries illness prepares community food. Because
104 Chapter 8
of its insidious nature, the disease is not of preparing food. In an epidemic situation,
generally recognized until jaundice appears, search should be made for the origin of the
by which time infection may have been outbreak and preventive measures taken. In
widely transmitted. the long term, water supplies and sanitation
Hepatitis is mainly a disease of poor should be upgraded.
sanitation, with water and food as the prin- HAV vaccine protects the individual at
cipal vehicles of transmission, but can also risk and should be mandatory for those going
occur when sanitation is good. Salads, cold from an area of good sanitation to one of
meats and raw sea food are common poor sanitation, such as tourists and expatri-
vehicles of transmission. ates. Two doses are required to be given
The carrier state is not important, but a 618 months apart, although one dose still
large number of asymptomatic cases are gives high levels of immunity. Immunity
produced. Epidemics occur when sewage from a two-dose regime may be lifelong, but
contaminates water supplies producing in- a booster at 10 years is currently recom-
fection in people who have previously mended. As most of the population in an
acquired some immunity, suggesting that endemic area would have met the infection
the disease may be dose-dependent. Where as children and either had no symptoms or
there is a large infecting inoculum, infection just a mild infection, there is no case for mass
can occur despite previous experience of the vaccination, except for high-risk groups.
disease. Chimpanzees and other animals
have been found infected, but probably Treatment There is no specific treatment
have no epidemiological significance. and supportive measures should be under-
taken. Fatty foods should be avoided and a
Incubation period is 1550 days, generally good fluid intake maintained.
about 28 days.
Surveillance Once hepatitis has been
Period of communicability is the later half of detected, health authorities should notify
the incubation period until about 1 week central authorities and surrounding areas.
after jaundice appears, so that most cases
have already transmitted the virus to family
and contacts before they report for medical 8.9 Hepatitis E (HEV)
attention.
Organism An enteric (E) virus provisionally
Occurrence and distribution Hepatitis is en- classified as a calicivirus.
demic in most tropical countries, with chil-
dren coming into contact early in life and Clinical features Hepatitis E is very similar
developing a degree of immunity. Non- to hepatitis A except that it nearly always
immune persons, such as from an area of occurs in large epidemics. The main differ-
good sanitation coming into this environ- ence is that hepatitis E results in a high
ment, are likely to develop the disease. Epi- mortality in pregnant women (up to 20%).
demics occur in developed countries,
especially in institutions, such as schools Transmission Similar to hepatitis A, al-
and prisons, due to poor food hygiene. though the main means of transmission is
via water. A reservoir has been found in
Control and prevention During an outbreak wild and domestic pigs, suggesting a zoono-
of hepatitis A, extra effort should be made to tic pattern of transmission.
encourage scrupulous personal hygiene
with hand-washing. Anybody who starts to Diagnosis is by the detection of IgM and IgG
feel unwell should be temporarily relieved anti-hepatitis E virus (anti-HEV) in serum.
Incubation period 39 weeks. be a history of normal birth with commence-

ment of walking, followed by a feverish
Period of communicability From 14 days illness and the development of flaccid par-
after the appearance of jaundice for a further alysis. The paralysis is limited to well-
2 weeks. demarcated muscle groups and there is no
sensory loss. A similar history may be given
Occurrence and distribution Hepatitis E has for meningitis, but the damage will be
been responsible for large epidemics in central with accompanying mental defi-
South and Southeast Asia, especially Myan- ciency.
mar and Vietnam, where it appears to be
endemic. Epidemics have also occurred in Transmission is generally via the faecaloral
North Africa, Ethiopia, China and Mexico. route, although the virus initially multiplies
in the oro-pharynx; hence airborne trans-
Control and prevention The same as hepa- mission can also occur. The virus then in-
titis A, but extra precautions should be vades the gastro-intestinal tract, where it is
taken to protect pregnant women. There is excreted for several weeks.
no specific vaccine. A disease of low hygiene, young chil-
dren (45 months) meet the virus with only a
small proportion showing overt disease. Of
these, 8090% have an inapparent sub-
8.10 Poliomyelitis (Polio)
clinical disease, 510% suffer from fever,
headache and minor clinical signs, with
Organism Poliovirus (Enterovirus) types 1, 2 only 1% going on to paralysis. Paralysis is
and 3. more common with older age. Therefore, a
non-immune person going into an endemic
Clinical features Infection commences with environment is at far greater danger of de-
fever, general malaise and headache, the ma- veloping paralytic poliomyelitis. Raising
jority of cases resolving after these mild standards of hygiene will also have the
symptoms, but approximately 1% proceed same effect because it spares people from
to paralytic disease. The virus has a predi- meeting the virus as young children and
lection for nerve cells, especially those with allows a pool of susceptibles to develop. In
a motor function (the anterior horn cells of the course of time, the number of non-
the spinal cord and the motor nuclei of the immunes will be sufficient for an epidemic
cranial nerves). These cells are destroyed to take place. There will also be a higher
and a flaccid paralysis results. proportion of paralysed cases (peak age
As a generalization, paralysis is more 59 years) and many deaths. Sadly, the rais-
common in the lower part of the body, being of living standards will change polio
coming less common the higher up it from an endemic disease with a few para-
affects. Unilateral lameness is more lysed cases to an epidemic disease of in-
common than bilateral lameness. The severe creased severity. In epidemic poliomyelitis
form of bulbar poliomyelitis is generally where sanitation is good, pharyngeal spread
fatal in poor countries where respirators becomes a more important method of trans-
and intensive nursing care are not available. mission.
Site of paralysis is associated with injections Poliovirus strains vary in their neuro-
or operations and such procedures should virulence with the more virulent strains
be avoided if there is any suggestion of having a greater tendency to spread. This
poliomyelitis. could be due to a lower infective dose of
the virulent virus being required to produce
Diagnosis of the disabled case is made on disease.
clinical grounds, differentiating from the
spastic paralysis of birth injury with which Incubation period is from 5 to 30 days with a
it is commonly confused. In polio, there will mean of 10 days.
106 Chapter 8
Period of communicability From 2 days after There is a slight risk of a live attenuated
exposure up until 6 weeks. virus becoming more virulent, so it is prefer-
able to vaccinate the majority of the popula-
Occurrence and distribution Poliomyelitis tion all at one time. Also, in a situation of
formerly occurred throughout the world, en- raising sanitary standards, epidemic polio-
demic in the poorer regions and epidemic in myelitis will only be prevented if there are
those with good sanitation, but this has sufficient people immunized to produce
changed considerably with the WHO pro- herd immunity. For these reasons, mass
gramme of eradicating polio from the campaigns can be effective. These should
world. The Americas, Europe and Western always be followed up by static clinics vac-
Pacific are now free of infection, while there cinating newborns and missed persons. The
are very few cases remaining in the rest of WHO, in its bid to eradicate polio from the
the world. The end of 2005 has been set world, recommends National Immunization
as the target date for global eradication of Days (NID) on which all children under the
polio. age of 5 years are vaccinated, irrespective of
previous immunization status. Two doses
Control and prevention The main method of are given at a months interval followed by
prevention and control is with polio vac- mop-up operations in areas of low coverage
cine. Two types of vaccine are available, or where continuing transmission has been
the killed (Salk) and the attenuated living identified.
(Sabin). The Salk vaccine is given by intra- School children and adults, who have
muscular injection, inducing a high level of received a full course of childhood vaccin-
immunity not antagonized by inhibitory ations, should have booster doses every
factors in the gut, but is expensive to pro- 10 years. Maintenance of vaccination cover-
duce because it contains many organisms. age should continue even in countries now
The Sabin vaccine is administered orally free of infection and is essential for travel to
making it easier and cheaper as well as pro- parts of the world where polio has not yet
ducing intestinal immunity, which can been eradicated.
block infection with wild strains of polio- The long-term aim of prevention should
virus. Multiplication of the virus in the be to raise standards of hygiene with the
intestine makes it very useful in preventing provision of water supplies and sanitation,
epidemics and allows it to spread to non- but as mentioned above, this must proceed
vaccinated persons in conditions of poor at the same time as an adequate vaccination
hygiene, thereby protecting them as well. programme.
Unfortunately, the inhibiting action of anti-
bodies in breast milk and colonization of the Treatment There is no specific treatment for
gut by other entero viruses can reduce its the acute stage, but rest and the avoidance of
effectiveness. Increasing the dosage and tell- physical activity are beneficial. Specific
ing mothers not to breast-feed for at least an supportive measures can be given to those
hour after administration can help. with disabilities.
Because there are three strains of the
poliovirus, the vaccine should be given on Surveillance developed for poliomyelitis
three separate occasions, separated by eradication looks for cases of acute flaccid
periods of at least 1 month to ensure that paralysis (AFP) in children under 15 years
immunity develops to each of the strains. of age. These are investigated by stool exam-
Polio vaccine is conveniently administered ination, inquiry and search for other cases
at the same time as DTP. A preliminary dose in the area. Remedial measures are carried
can be given soon after birth in areas where out around the case, vaccinating all con-
wild poliovirus is circulating. tacts.
8.11 Enterobius (Pin Worm) Period of communicability As long as adult

female worms discharge eggs until 2 weeks
Organism A nematode worm Enterobius after treatment.
vermicularis.
Occurrence and distribution This very
Clinical features The main symptom is in- common infection is more prevalent in the
tense pruritis ani. Heavy infections can temperate than tropical regions of the world,
rarely cause appendicitis or salpingitis in favouring conditions where poor hygiene
the female. prevails.
Transmission The gravid female migrates out Control and prevention Good personal hy-
of the anus at night to lay her eggs on the giene, particularly cutting of finger nails
perianal skin before dying. This activity of and washing hands, is the means of control.
the female causes the patient to scratch so Bedding and underclothes need to be
that eggs are transferred to the fingers where washed frequently at the same time as treat-
they are swallowed or passed on to someone ment is given.
else. Eggs are thrown into the air such as
during bed making or sweeping and so are
often inhaled. Masses of eggs are liberated Treatment is with piperazine 65 mg/kg for
on each occasion so that infection of family 7 days, pyrantel pamoate in a single dose of
groups, dormitories of school children, etc. 10 mg/kg (maximum 1 g), repeated after
occur at the same time. 2 weeks, or albendazole or mebendazole
100 mg single dose repeated after 2 weeks.
Diagnosis Eggs can be collected from It is preferable to treat everyone in the
the perianal skin by using an adhesive tape group at the same time to break the transmis-
slide. This is examined directly by micro- sion cycle.
scope, the characteristic oval egg with flat-
tened side measuring 5060 mm by 20 Surveillance Regular checks in an institu-
30 mm (Fig. 9.1) being seen. tional situation, especially on individuals
with repeat infections will prevent spread
Incubation period 26 weeks. throughout the establishment.
9
Food-borne Diseases
The faecaloral mechanism for transfer of group of persons who have shared the same
infection often includes food as a mechan- meal. Sometimes, a sub-normal temperature
ism of infection, but in addition, there are or lowered blood pressure is the presenting
other diseases that are only transmitted by symptom. The incubation period is very
food. These can infect foods in general, such short and sufficiently precise for the type of
as with food poisoning, or be very specific in food poisoning to be suspected by the length
a particular food, such as certain helminth of time since the food item was eaten.
infections. As the method of infection is very
specific so are its methods of control, which Incubation period With staphylococcal food
include food hygiene, the proper cooking of poisoning, it is between 1 and 6 h; Salmon-
foods and sanitary methods to prevent the ella over 6 h, usually 1236 h, and for Clos-
food from being contaminated. tridia, 1224 h or several days. Less
commonly, food poisoning can be due to
Bacillus cereus (112 h) and Vibrio parahae-
9.1 Food Poisoning molyticus (1248 h).
9.1.1 Food poisoning due to bacteria Transmission is through the consumption of

food contaminated with the bacteria or its
Organism Food poisoning can either be due toxins. Infection can sometimes result from
to bacteria, viruses, organic or inorganic a contaminated water supply and via milk
poisons (Table 9.1). The most common that has not been pasteurized. Salmonella
poisoning is that produced by bacteria. The generally infects the food in the living
main types of bacterial food poisoning are state, such as cattle, poultry or eggs, but
due to Salmonella, Staphylococcus or Clos- unhygienic practice in the slaughtering of
tridia. animals or preparation of foodstuffs can
also be responsible. The bacteria are killed
Clinical features Due to the similarity of pre- by proper cooking and no toxins are pro-
sentation, it is more convenient to consider duced; so examination of the meal should
them as a group, rather than individually. reveal an improperly cooked source.
Onset is sudden with fever, generally Staphylococcal food poisoning results
vomiting and/or diarrhoea in a family or from toxin produced by the bacteria so the
108
Food-borne Diseases 109
Table 9.1. Food poisoning.
Agent Period of onset (h) Symptoms Types of food
Bacterial food poisoning

Staphylococcal 16 Sudden, vomiting more Stored food
B. cereus 112 than diarrhoea
Salmonella 1236 Vomiting, diarrhoea and Improperly cooked meat,
fever eggs and milk produce
C. perfringens 924 Abdominal cramps, Cooked meat, especially
diarrhoea, shock pig
C. botulinum 924 Ptosis, dry mouth, paralysis Preserved foods
V. parahaemolyticus 1248 Abdominal pain, diarrhoea Undercooked or raw fish
and fever
Fish poisoning
Ciguatera 130 Parathesiae, malaise, Barracudas, snappers, sea
sweating, diarrhoea and bass, groupers
vomiting
Scombroid 112 Burning sensation, nausea, Tuna, mackerel, salmon or
vomiting cheeses
Tetraodontoxins 0.53 Hypersalivation, vomiting, Puffer fish
parasthesiae, vertigo,
pains
Shellfish, paralytic 0.53 Parasthesiae and paralysis Clams and mussels
Shellfish, diarrhetic 0.53 Diarrhoea and vomiting Clams, scallops, etc.
Plant foods
Akee (Blighia sapida) 23 Vomiting, convulsions, Unripe fruit
death
Cassava (Cyanide) Hours Vomiting, diarrhoea, Improperly processed root
abdominal pain,
headache, coma
Contaminants
Triorthocresyl- Days Neuropathy Cooking oil
phosphate
food may be adequately cooked and no bac- ease of short duration, but in New Guinea
teria isolated from the suspected food and the Western Pacific Islands, it is respon-
source. It is commonly transmitted by food sible for enteritis necroticans or pigbel, in
handlers with an infected lesion or un- which there is an acute necrosis of the
hygienic habits, such as transferring bacteria small and large intestines with a high fatal-
from the nose. V. parahaemolyticus is par- ity rate. This is associated with feasting,
ticularly associated with seafood or food generally of pig meat, but also from other
that has been washed with contaminated animals such as cattle. Children, particu-
seawater. larly boys, are mainly affected. The disease
Clostridia food poisoning can be caused is probably accentuated by a protease inhibi-
by several types of organisms. C. botulinum tor contained in sweet potato, preventing
infection results in a severe disease, botu- breakdown of the toxin.
lism, which is characteristic of home-pre- Clostridia have resistant spores, which
served foods (see further Section 18.5). C. can remain in the soil for long periods, and
perfringens generally produces a mild dis- their contamination of partly cooked and
110 Chapter 9
re-heated food allows multiplication and amongst food handlers. Anyone with a
production of the toxin. septic or discharging sore should be banned
There is often a seasonality of food from handling and preparing food.
poisoning, Salmonella in the summer Food must be stored, prepared and
months and C. jejuni in spring and autumn. cooked properly (Section 3.3.2). Establish-
C. perfringens occurs throughout the year. ments that prepare food, such as restaurants
and hotels, should be regularly inspected
Diagnosis and investigation of the and certified.
outbreak The epidemiologist is concerned
with diagnosing the cause of the outbreak Treatment The treatment of cases of food
and, therefore, a search is made to discover poisoning is supportive with fluids and
a common food that has been eaten by all electrolytes (either orally or intravenous).
the persons who have succumbed to the
illness. The foodstuff is likely to be one par- Surveillance Food handlers should be
ticular ingredient of the meal, rather than checked by supervisors and food establish-
the whole meal and samples should be ments visited on a regular basis by health
taken for culture. If nothing is grown, this inspectors.
does not rule out a Staphylococcal or
Clostridia food poisoning cause and finer
questioning on foodstuffs consumed might 9.1.2 Fish poisoning
be the only way to discover the offending
item. (See Section 2.2.5 on how to analyse
Organism Fish poisoning is a specific form
the relative importance of different foods
of food poisoning caused by toxins present
eaten.)
in the fish or shellfish when they are caught
or which develop due to partial decompos-
Period of communicability In Salmonella in- ition taking place if they are not eaten
fection, organisms can be excreted for up to straight away or refrigerated. Ciguatera
1 year although it is generally just for a toxin is produced by the dinoflagellate Gam-
period of weeks. bierdiscus toxicus, which is present in
algal blooms, often called red tides, while
Occurrence and distribution Food poisoning shellfish poisoning can de due to the dino-
is found worldwide with large outbreaks as- flagellates Gonyaulux, Gymnodinium,
sociated with gatherings of people, such as Dinophysis or Alexandrium.
celebrations and weddings. Many small out-
breaks and those occurring in the home go Clinical features Symptoms are normally
unreported unless individuals are ill mild with paraesthesia (tingling and burn-
enough to be hospitalized. Sometimes a ing sensations or pain and weakness), mal-
batch of food is infected and distributed to aise, sweating, diarrhoea and vomiting, but
several outlets, so as soon as the food- in the young or those who have consumed a
poisoned item is discovered, all of it must large quantity of poison, the condition is
be traced and destroyed. more serious. Respiratory and motor paraly-
sis can occur, often resulting in fatalities.
Control and prevention All suspect food Neurological symptoms can persist for
must be destroyed and if it is part of a some time after the original illness.
common foodstuff, then all must be traced
and disposed of. The source of contamin- Transmission is through eating fish that has
ation, such as an abattoir, must be looked not been refrigerated or already contains the
for and control measures implemented. Pre- toxin. At certain times of the year and when
vention is by proper cooking of food and hurricanes, seismic shocks or similar dis-
personal hygiene. Where repeated attacks turbances of the coral reef occur, an
occur, a search for a carrier should be made algal growth containing the dinoflagellate
develops. Fish feed on the algal bloom, or it bizarre symptoms, such as paralysis, may
is inadvertently filtered by shellfish, and be caused by an organic or inorganic poison
their flesh becomes poisoned. Fish that are contaminating the food. Examples are cyan-
normally quite edible, such as barracuda, ide poisoning from poorly processed bitter
snappers, sea bass and groupers, become cassava, eating unripe akees (a fruit popular
poisonous at these periods. The commonest in the Caribbean) or contaminants in
poison is ciguatoxin, which is not destroyed cooking oil.
by cooking. Although very localized, such out-
breaks can be serious with considerable
Incubation period 0.53 h after eating fish or morbidity and sometimes mortality, neces-
shellfish. sitating the identification of the source as a
matter of urgency and banning them from
human consumption.
Period of communicability Not transmitted
from person-to-person.
9.2 Campylobacter Enteritis
Occurrence and distribution Fish poisoning
is commonly found amongst island commu- Organism Campylobacter jejuni.
nities or coastal people in which fish is a
major item of diet. It is an important problem
Clinical features An acute diarrhoeal disease
in Pacific Islands, the Caribbean, Southeast
with abdominal pain, malaise, fever and
Asia and Australia.
vomiting. It is often self-limiting within 4
7 days, but in severe cases, pus and blood are
Control and prevention All freshly caught found in the stools, with a presentation
fish should be gutted and refrigerated as similar to bacillary dysentery. With its asso-
soon as caught, unless cooked and eaten ciation with a food source, it is often thought
straight away. Red tides (algal blooms) to be a case of food poisoning until the or-
occur as a result of some disturbance ganism is identified. Campylobacter enter-
of coral reefs, such as hurricanes, earth- itis is an important cause of travellers
quakes and El Nino climatic disturbances. diarrhoea.
Algal blooms and hence fish poisoning
are related to the surface temperature. As Diagnosis The organism can be isolated
a result, where this is abnormally increased from the stools using selective media. A pre-
during an El Nino event, there is an in- liminary diagnosis can be made by examin-
crease in fish poisoning and the converse ing a specimen of stool with phase-contrast
when the temperature is less than (dark-ground) microscopy, where an organ-
expected. ism similar to a cholera vibrio will be seen.
The presence of faecal material and absence
Treatment There is no specific treatment; of cholera-like symptoms will differentiate
supportive therapy being given. it from cholera.
Surveillance When red tides are reported, Transmission Domestic animals including
eating reef fish should be avoided. poultry, pigs, cattle, sheep, cats and dogs
are reservoirs of the organism and their
consumption or humans close association
9.1.3 Food poisoning due to organic or with them is responsible for much
inorganic toxins of the transmission. Most infections are
due to faecal contamination by animals or
More generalized outbreaks involving large birds, especially of unpasteurized milk
numbers of people not necessarily associ- and unchlorinated water. Water can be con-
ated with each other and presenting with taminated by bird droppings in which the
112 Chapter 9
organism is able to survive for several ment. This sometimes leads to abscess and
months at a temperature below 158C. Many haemorrhage, but as well as these local
infections are transmitted by pets, espe- effects, the parasite produces toxins. These
cially puppies and person-to-person trans- can lead to oedema, weakness and prostra-
mission can occur in a similar way. tion, ending fatally in the debilitated child.
Incubation period 110 days. The larger the Diagnosis is made by finding the egg in
dose of organisms ingested, the shorter the faeces, a giant among parasites (Fig. 9.1).
incubation period. The egg is indistinguishable from Fasciola
hepatica (see Section 9.4).
Period of communicability 27 weeks, but
person-to-person transmission is uncom- Transmission The eggs are passed in faeces
mon. either directly into water or are washed
there following rains, where they hatch and
Occurrence and distribution Children under liberate a miracidium, which must find a
2 years of age are most commonly infected snail of the genus Segmentina. Developing
in developing countries, immunity develop- first into a sporocyst, then a redia, numerous
ing to further infection in those over this cercaria are produced. On leaving the snail,
age. There is a worldwide distribution with the cercaria encyst on water plants that are
many of the cases in developing countries subsequently eaten raw by humans (Fig.
not being identified. There has been a 9.2). These plants include the water calthrop
progressive increase in Campylobacter (Trapa sp.), the water chestnut (Eliocharis
for no explainable reason. It is one of the tuberosa) and the water bamboo (Zizania
commonest causes of gastroenteritis aquatica). Beds of these water plants are
(Section 8.1). often grown in ponds fertilized by human
sewage, providing considerable opportunity
for transmission. Even if the foods are sub-
Control and prevention Proper cooking of sequently cooked, they are often first peeled
foodstuffs and control of pets are the main with the teeth so that cercariae are still
preventive methods. Wherever possible, swallowed.
water should be chlorinated and milk pas- A reservoir of infection is maintained in
teurized. pigs, sheep, cattle and other domestic herbi-
vores. Infection is particularly high in pig-
Treatment Oral rehydration. rearing areas. Humans also act as reservoirs.
Surveillance and investigation An outbreak of Incubation period 23 months.

Campylobacter should be investigated in
the same way as a food-poisoning outbreak Period of communicability is 12 months, but
and remedial measures taken around the animals act as a permanent reservoir.
source.
Occurrence and distribution East Asia, espe-
cially China, Taiwan, Thailand, Borneo and
9.3 The Intestinal Fluke (Fasciolopsis) Malaysia, in some 15 million people.
Organism The large human fluke Fasciolop- Control and prevention is by the proper
sis buski. preparation and cooking of water plants.
Much can be done to reduce transmission
Clinical features The adult worm lives in the by regulating the use of human faeces as a
small intestines and produces damage by fertilizer. Domestic animals should be kept
inflammatory reaction at the site of attach- away from water plant cultivation ponds.
Ascaris Hookworm Trichuris Enterobius
Taenia H. nana
H. diminuta Balantidium
(cyst)
Sputum or faeces
Opisthorchis
Heterophyes Diphyllobothrium Paragonimus
F. hepatica & F. buski
Trophozoite
Giardia
cyst S. japonicum
S. mansoni S. haematobium
E. coil E. histolytica E. nana
0 10 30 50 100 m
Fig. 9.1. Parasite eggs found in faeces, urine and sputum. E. (nana), Endolimax; E. (coli), E. (histolytica),
Entamoeba; F. (hepatica), Fasciola; F. (buski), Fasciolopsis; H. (diminuta), H. (nana), Hymenolepis; S.
(haematobium), S. (japonicum), S. (mansoni), Schistosoma.
114
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm
Fasciola hapatica
Fasciolopsis buski
Chapter 9
Segmentina
(F. buski)
Redia in snail
Cercaria
Watercress
Egg of Water calthrop Grasses
F. hepatica or Water chestnut
Miracidium
F. buski Water bamboo
Lymnaea
(F. hepatica)
page 114
Fig. 9.2. The intestinal (Fasciolopsis) and sheep liver (Fasciola) flukes.
Treatment is with praziquantel 25 mg/kg found in Africa and the Western Pacific;
three times a day for 12 days. 2.5 million are probably infected in the
world, with up to 60% of the population in
Surveillance When a case is diagnosed, highly endemic areas.
other members of the family should be in-
vestigated and a common food source Control and prevention In known endemic
looked for. areas, careful control is required in the grow-
ing and consumption of water plants such as
cress. Animal faeces should not be used to
9.4 The Sheep Liver Fluke (Fasciola fertilize water plants. The close association
hepatica) of humans and sheep or other domestic
animals greatly increases the opportunity
Organism The sheep liver fluke Fasciola for infection.
hepatica. Less commonly F. gigantica.
Treatment Triclabendazole at 10 mg/kg
Clinical features The parasite has a single dose, which can be repeated after 12 h.
predilection for the liver, piercing the gut
wall and migrating through the liver sub- Surveillance Sheep should be examined at
stance to lie in the biliary passages. This regular intervals and treated.
migration and residence in the liver causes
extensive damage, leading to fibrosis and
cirrhosis. 9.5 The Fish-transmitted Liver Flukes
Diagnosis is made by finding the very large Organism The trematode fluke Opisthorchis
egg in the stool, which is almost identical to sinensis (previously called Clonorchis).
that of Fasciolopsis (Fig. 9.1).
Clinical features The adult fluke lives in the
Transmission The life cycle is similar to Fas- branches of the bile duct resulting in trauma
ciolopsis in that eggs passed in the faeces and inflammation. Dilation of the biliary
liberate a miracidium on contact with system causes a distortion of the liver archi-
water. The miracidium searches for and in- tecture, which can lead to biliary stasis, hep-
vades snails of the genus Lymnaea. After atic engorgement, fatty infiltration and
passing through sporocyst and redia stages, finally cirrhosis. O. sinensis is a risk factor
the cercaria encyst on grass or water plants for cholangiocarcinoma. Migration of the
(e.g. water cress). The normal life cycle is in flukes up the pancreatic duct can damage
sheep, humans becoming incidentally the pancreas leading to recurrent pancrea-
infected when contaminated water plants titis.
are eaten (Fig. 9.2). Cattle and goats also act
as reservoirs. Diagnosis The small operculated egg is
found on faecal examination (Fig. 9.1).
Incubation period Probably 23 months.
Transmission Humans are infected by eating
Period of communicability Not transmitted raw fish, which includes pickled, smoked or
from person-to-person. undercooked fish. Eggs passed in the faeces
develop into miracidia, which are swal-
Occurrence and distribution Worldwide lowed by snails of the genus Bulimus, Bi-
distribution in sheep-rearing areas, espe- thynia or Parafossarulus. These pass
cially the Andean highlands of Bolivia, through the sporocyst and redia stages in
Ecuador and Peru, the Nile delta region of the snail and produce free-swimming cer-
Egypt and northern Iran. F. gigantica is caria. Seeking out a suitable fish, cercaria
116 Chapter 9
penetrate between the scales and encyst in Period of communicability Eggs may be
the flesh. The parasite also attacks dogs, passed for as long as 30 years, but reservoir
cats, rats and pigs, which form reservoirs of animals are also an important source of
infection (Fig. 9.3). human infection.
Occurrence and distribution Distribution is

very similar to Fasciolopsis, being found in
Incubation period Approximately 4 weeks. China, Japan, Korea, Taiwan, Thailand,
Eggs ingested
by snail
Bulimus or
Bithynia
snails
Redia Cercariae encyst

under fish scales
Fig. 9.3. The fish-transmitted liver flukes, Opisthorchis sinensis, O. felineus, O. viverrini, H. heterophyes and
M. yokogawai.
Laos, Cambodia and Vietnam (lower include cough and chest pain. If the parasite
Mekong valley). Some 30 million people migrates to a site other than the lung, it can
suffer from the disease. cause CNS, liver, intestinal, genitourinary or
subcutaneous disease.
Control and prevention Control is by the
proper cooking of fish. Members of the
Diagnosis is by finding eggs in the sputum,
carp family (Cyprinidae), the so-called
or if swallowed, in the faeces (Fig. 9.1). Any
milk fish, are eaten raw as a delicacy.
case of haemoptysis without other signs of
They are grown in fish farms as part of
tuberculosis should have a sputum examin-
a system of aquaculture, fertilized by
ation, on which an acid-fast bacilli (AFB)
human faeces. Regulation of this practice
stain has not been used, as this destroys the
is required to reduce this unpleasant
eggs.
infection. Other foods, such as fish paste
often added to food after it has been
cooked to improve the taste, are made Transmission The egg on reaching water
from raw fish and are a potent source of softens and a miracidium frees itself from
infection. the egg capsule and searches for a snail of
the genus Semisulcospira. Passing through
Treatment Treatment is with praziquantel the sporocyst and redia stages, the cercaria
25 mg/kg three times a day for 12 days. encysts in the gills and muscles of fresh-
water crabs and crayfish. Humans are
Surveillance When a case is identified, infected by eating uncooked, salted or
search should be made for the culprit food pickled freshwater crab (Eriocheir and Pota-
source. mon) or crayfish (Cambaroides), while an
There are a number of less common animal reservoir (mainly cats and dogs)
trematodes that have the same life cycle as helps to maintain the disease. The liberated
O. sinensis (Fig. 9.3). O. viverrini is found in metacercaria pass through the intestinal
Thailand and Laos where raw fish paste is a wall and penetrate the diaphragm to enter
favourite food additive. O. felineus occurs in the lung. Adults develop in the lungs to
Central and Eastern Europe, similarly caus- produce eggs, which are liberated into the
ing disease of the liver. As suggested by its sputum. Occasionally they find their way to
name, it is mainly a disease of cats, but unusual sites, the brain being particularly
humans can become infected. Heterophyes serious (Fig. 9.4).
heterophyes and Metagonimus yokogawai,
found in Asia and the Far East, do not attack
Incubation period 610 weeks.
the liver, but remain in the intestines. The
eggs of all of these flukes are very similar
(Fig. 9.1). Period of communicability Up to 20 years.
Occurrence and distribution P. westermani

9.6 The Lung Fluke disease is found mainly in China, other
parts of Asia, Africa and the Americas.
Organism Unique amongst all the hel- Closely related species are P. africanus
minths, the trematode Paragonimus wester- and P. uterobilateralis in West Africa, P.
mani selectively inhabits the lung. pulmonalis in Japan, Korea and Taiwan,
P. philippinensis in the Philippines, P. het-
Clinical features Foreign body reaction erotremus in Thailand and Laos, P. kellicotti,
to the parasite in the lung results in fibrosis, P. caliensis and P. mexicanus in Central
compensatory dilation and abscess forma- and South America. In all, it has been
tion. Haemoptysis is often an important calculated that some 30 million people
feature, mimicking tuberculosis. Symptoms suffer from the lung fluke.
118 Chapter 9
Eggs
passed
in sputum
Cercaria
or faeces Redia
Metacercaria
in crab gills
Sporocyst
Miracidium
Semisulcospira
Fig. 9.4. The lung fluke Paragonimus westermani.
Control and prevention Control is most Diagnosis is made by finding the egg in the
effectively achieved by ensuring that all faeces (Fig. 9.1). Sometimes, worm segments
crab and crayfish meat is properly cooked. (proglotids) are also passed.
Much can be achieved by teaching people
about the life cycle of this and other trema- Transmission The adult worm is found in
tode infections, stressing that all food must the intestines of humans, dogs, cats, foxes
be cooked and faeces disposed of properly. and bears, and a number of other mamma-
Spitting should be outlawed. lian hosts. Eggs are passed in the faeces,
which on contact with water liberate a cor-
Treatment is by praziquantel 25 mg/kg three acidium, which is ingested by a copepod
times a day for 2 consecutive days. Alterna- (Cyclops and Diaptomus). The coracidium
tively, triclabendazole 10 mg/kg, repeated in develops in the copepod to a larval form, a
12 h, can be used. procercoid, which when eaten by a fresh-
water fish finds its way into the muscles
Surveillance It is a focal disease so that iden- and develops into a plerocercoid. When the
tifying a case will often lead to a foci of raw or improperly cooked fish is eaten,
infection and preventive action can then be the liberated plerocercoid attaches itself
instituted. to the intestinal wall and develops into an
adult tapeworm (Fig. 9.5).
9.7 The Fish Tapeworm Incubation period 36 weeks.
Organism The large tapeworm Diphyllobo- Period of communicability Humans can con-
thrium latum. tinue to liberate eggs into the environment
for many years, but most of the infective
Clinical features The presence of such a source is from the animal reservoir.
large worm (10 m or more) in the intestines
can consume a considerable quantity of Occurrence and distribution The parasite is
nutrients, but the main pathology is due to found in the cooler parts of the world,
its selective absorption of vitamin B12, around lakes of Europe, America, China
resulting in a megaloblastic anaemia in the and Japan. It is also found in indigenous
host. tribes living in the Arctic and sub-Arctic
Gravid segment
Eggs passed
in faeces
Plerocercoid in fish
Coracidium
hatched in
water
Procercoid in
copepod
Fig. 9.5. The fish tape worm Diphyllobothrium latum.
regions. It is a disease of some 13 million Treatment Niclosamide as a single dose of

people. 2 g or praziquantel as a single dose of
510 mg/kg.
Control and prevention Control is by
ensuring that fish are properly cooked.
Deep-freezing fish will also kill the parasite. 9.8 The Beef and Pork Tapeworms
Sanitation will decrease the human cycle
and animal faeces should be prevented Organism Taenia saginata, the beef tape-
from entering water sources. worm and T. solium the pork tapeworm.
120 Chapter 9
Clinical features The adult worm of both also been found that birds feeding on sewage
species can live in the intestines producing can carry eggs for long distances and then
little pathology, being diagnosed often by deposit them on pasture land. Flies might
accident. It does, however, share the food have a place in transmission. The eggs de-
supply of its host so that when intake is velop into cysticerci in the muscles,
inadequate, debility can occur. The serious favouring the jaw, heart, diaphragm, shoul-
problems are due to the Cysticercus cellulo- der and oesophagus. Humans acquire the
sae (from T. solium). The cysts die and cal- disease by eating improperly cooked beef
cify, those in the brain being a common or pork containing the cysticercus.
cause of epilepsy or mental disorder. Both the beef tapeworm (T. saginata)
and the pork tapeworm (T. solium) have
Diagnosis is made by finding the proglottids the same life cycle except that the intermedi-
(worm segments) in the faeces, the patients ate stage, the cysticercus of T. solium, can
often making their own diagnosis. It is very also occur in humans. This happens by
important to distinguish between T. sagi- swallowing eggs directly, either by auto-
nata and T. solium in view of the danger of infection, from eggs in food or water or
inducing cysticercosis. T. saginata has 18 through sewage contamination. Also any
30 compound branches of the uterus on each gastric disturbance that might cause the re-
side whereas T. solium has only 812 (Fig. gurgitation of proglottids into the stomach
9.6). (including improper treatment) can lead to
the liberation of vast quantities of eggs, with
Transmission The adult worm lives in the the result that cysticerci are produced any-
small intestine of man and as it matures, where in the body including the brain, orbit
gravid segments break off and are passed in and muscle.
the faeces. Cattle or pigs inadvertently eat
the proglottids (mature segments) or the dis- Incubation period 814 weeks.
charged eggs contaminate the pasture. Alter-
natively, the animal can become infected by Period of communicability Adult worms
drinking water polluted by sewage. It has can live for as long as 30 years, their eggs
T. saginata
T. solium
Cysticercus
in muscle
Proglottid
Egg
Fig. 9.6. The tape worms Taenia solium and T. saginata.

contaminating the environment and in ing in official abattoirs, with meat inspec-
T. solium a direct threat to any other person. tion, can prevent the dissemination of
infected meat. Condemned carcasses must
Occurrence and distribution These are the be burnt.
commonest and most cosmopolitan of all
the tapeworms, with a worldwide distribu- Treatment for both worms is with niclosa-
tion in beef- and pork-eating areas, espe- mide 2 g as a single dose. Alternatively, pra-
cially in the tropical belt and Eastern ziquantel as a single dose of 510 mg/kg can
Europe. Over 60 million people are thought be given. Praziquantel at a dose of 50 mg/kg
to be infected. for 15 days can be used for cerebral cysticer-
These two worms are found in areas of cosis in conjunction with corticosteroids, as
beef and pork eating where there is a ready an in-patient.
transmission cycle in operation. Finding the
worm in humans means that it is probably Surveillance Where a localized cycle of in-
reasonably common in that area, whereas fection is occurring, investigation may
other places where beef and pork eating are reveal a sewage leak or other source of con-
just as much part of the usual diet, they are tamination that could easily be rectified.
not found. T. saginata is increasing in
Europe probably because of human sewage
contamination of animal drinking water. T. 9.9 Trichinosis
solium is common in Mexico, Chile, Africa,
India, Indonesia and Russia. Organism Trichinella spiralis (Fig. 9.7),
T. nelsoni, T. nativa, T. britovi and T. pseu-
Control and prevention The main means dospiralis, nematode worms.
of control is the proper cooking of meat.
The underdone steak or joint of meat where Clinical features The severity of the disease
internal temperatures are not high enough depends upon the dose of larvae that
to kill the cysticercus are common ways have encysted in the tissues. During the
in which transmission can still take place second week of infection, there is headache,
despite cooking. Proper control of slaughter- insomnia, pain, dyspnoea and pyrexia with
Human eats
uncooked meat Lion
Leopard
Hyena
Jackal
Warthog
bushpig
Encysted larva
Fig. 9.7. Trichinella spiralis.

122 Chapter 9
oedema of the orbit and eosinophilia. If the animals are infectious, probably for the rest
symptoms are sufficiently severe, death can of their life due to repeated doses of
result; otherwise, once the attack is over, the infecting nematodes.
cysts cause no further trouble, gradually die
and calcify. Occurrence and distribution Approximately
40 million people of the worlds population
Diagnosis is made by muscle biopsy of the are affected although trichinosis commonly
deltoid or thigh muscles where the encysted occurs as a localized outbreak with a group of
larvae are found. people all contracting the disease at the same
time. A classic example is for a wild pig to be
Transmission The life cycle is a simple one, killed and cooked over a fire by turning it on a
encysted larvae in the muscles are eaten by spit. By this means, only the outside meat is
another animal and the liberated larva de- well cooked and inside, the temperature has
velops into an adult to produce numerous not been sufficient to kill the larvae. Out-
new larvae, which are then carried to all breaks in the industrialized countries and in
parts of the body in the circulation. Only the urban areas of developing countries are
the larvae that reach striated muscle survive, commonly caused by eating sausages, espe-
the diaphragm, tongue, throat, eye and cially of the salami type.
thorax being the favoured sites.
In the different climatic zones of the Control and prevention All meat for human
world where different groups of animals consumption should be inspected. The cal-
live off each other, several transmission cified cysts can be detected with the naked
cycles have evolved. In Africa, the warthog eye and by cutting into the muscle. Where
and the bushpig form the vital link in the an outbreak occurs, such as with eating
cycle. Being the favoured prey of lions and sausages, the source should be investigated
leopards, these carnivores, with the hyenas and food hygiene practices enforced.
and jackals that finish off the remains, All meat must be properly cooked until
become infected. The general scavenging there is no redness in any part of the joint.
nature of the warthog and pig inadvertently Cooking slowly for a long time is preferable
eating the remains of dead animals allows to cooking quickly or on an open fire where
the cycle to be completed. Humans come in the outside gets overcooked while the inside
as intruders, a dead end to the cycle when remains almost raw. Deep freezing of meat
they feast on a recently killed bushpig. for 20 days or irradiation can kill the cysts.
In Europe and Asia, the rat is the reser-
voir of infection, but by its scavenging Treatment is symptomatic with steroids.
nature, the pig acquires infection and when Mebendazole or albendazole should also be
cooked on a spit or otherwise eaten in an given for 4 days.
improperly cooked way, humans become
infected. Sausages made from food scraps or
hamburgers contaminated with bits of pork Surveillance Where an outbreak occurs, the
can be potent sources. In the Arctic, the seal participants at the feast will all start having
and polar bear are involved in the transmis- symptoms at much the same time. By
sion cycle; the latter acquires very high levels counting back 2 weeks from these cases, the
of infection. The death of some Arctic ex- source of infection can be localized.
plorers has been attributed to killing and
eating polar bears infected with trichinosis.
9.10 Other Infections Transmitted
Incubation period 815 days. by Food
Period of communicability Not transmitted A number of other infections are also trans-
from person-to-person, but once infected mitted by food although their principal
method of transmission is by other means. also be transmitted by food, especially that

Any of the faecaloral diseases covered in grown in soil such as root crops and vege-
Chapter 8 can be transmitted this way ba- tables. Hydatid disease (Section 17.2) and
cillary dysentery, typhoid, hepatitis A, Giar- Toxoplasma (Section 17.5) can be acquired
dia and El Tor type cholera being spread by through food. Brucellosis (Section 17.6) is
eating salad vegetables, raw fish or other often transmitted in goats milk or cheese
food. The parasitic worms transmitted by made from it, while anthrax (Section 17.7)
soil contact, Trichuris, Ascaris, Strongy- can rarely be caught by eating the meat of a
loides and the hookworms (Chapter 10) can cow that has died from the disease.
10
Diseases of Soil Contact
The soil can be a source of infection for 10.1 Trichuris (Whip Worm)
several diseases particularly those caused
by nematodes and the bacterial infection, Organism The nematode Trichuris tri-
tetanus. Transmission can either be direct chiura, which has a characteristic egg
from contamination with the soil as with (elongated and with a knob at each end)
tetanus bacilli, by swallowing nematode when seen in faecal specimens (see Fig. 9.1).
eggs, or the larvae can penetrate the skin
when it comes into contact with the soil.
Developmental stages often take place in Clinical features A large number of people
the soil, which becomes a necessary envir- carry this infection quite asymptomatically,
onment for the life cycle. The promotion of but it has been realized that the debilitating
personal hygiene and preventing contamin- effect of this infection, especially in children
ation of soil through sanitation are the main in developing countries, can be quite consid-
methods of control for the nematode infec- erable. This is especially the case when tri-
tions and vaccination for tetanus. churiasis is associated with other common
Since there is a common mode of trans- infections, the combined effect leading to
mission for the three main nematode much ill health. When there are over 16,000
infections (Trichuris, Ascaris and the hook- eggs/g of faeces, a chronic bloody diarrhoea,
worms), they nearly always go together. As a anaemia, rectal prolapse and occasionally,
result, if the person is infected with one appendicitis can result. These infections
nematode, he or she is likely to have all tend to occur when the child eats earth
three infections. It is this combined effect (pica), which can be a result of iron defi-
that causes considerable morbidity in chil- ciency. Heavy infections are probably po-
dren in developing countries and if one tentiated by nutritional deficiencies,
looks again at Table 1.1, it will be noticed especially of zinc.
that having all three infections bring their
importance in terms of DALYs to the 12th Diagnosis The characteristic egg is easily
position. seen in a fresh faecal specimen (Fig. 9.1).
124
Diseases of Soil Contact 125
Transmission The egg develops in the soil 10.2 Ascaris

and when swallowed directly or as a con-
taminant of food, it changes into an adult in Organism The nematode worm Ascaris lum-
the caecum. Eggs are most commonly carried bricoides.
on the fingers or swallowed when the fingers
are licked. The soil is readily contaminated
Clinical features The fertile egg, when
from indiscriminate defecation, especially
swallowed, hatches in the stomach and the
where the faeces are not buried or a latrine
larva penetrates the intestinal mucosa to
used. Villages often have traditional places
enter the blood stream, passing through the
for defecation, thereby increasing the poten-
venous and pulmonary circulations to
tial for infection than when such customary
the lungs where it breaks through the
places are not the rule.
alveolar wall to emerge in the bronchioles.
Migrating up to a main bronchus, it ascends
Incubation period It takes 23 months for the trachea and is swallowed back into
eggs to be found in the faeces after eggs are the gastro-intestinal tract. By the time it
first swallowed, with symptoms occurring reaches the intestines, it has developed
about 1 month after ingestion. into an adult, the fertilized female laying
eggs into the excrement (Fig. 10.1). This
Period of communicability Persons can common intestinal parasite can occur in
remain infected for several years if not considerable numbers without causing
treated, continually contaminating the en- any symptoms and is often found when a
vironment if they have poor defecating routine stool examination is performed.
practices. When the larvae pass through the lungs,
pneumonitis and possible haemoptysis
can occur, otherwise the sheer number
Occurrence and distribution It is a very of worms can cause intestinal obstruction
common parasite (perhaps 540 million or blocking of vital structures, such as the
people are infected) and causes far more common bile duct. Where nutrition is mar-
disability than previously thought to be the ginal, the loss of nutrient can be sufficient
case (see Table 1.1). Most of the infection to tip a child into malnutrition. It has
with debilitating consequences occurs in been calculated that 25 worms can produce
developing countries, but the parasite is a loss of 4 g protein daily from a diet contain-
found worldwide. ing 4050 g protein. Deficiency of vitamins
A and C can also occur. Academic perform-
Control and prevention Washing hands ance in school decreases with heavy Ascaris
before having food and the careful prepar- infections.
ation of food are the main methods of con-
trol. Vegetables and root crops, in particular, Diagnosis Direct smear examination of the
must be washed carefully to remove all stool is sufficient for diagnosis (Fig. 9.1).
earth. Parents should discourage their chil- The egg has a strong outer coat, which is
dren from eating earth and have anaemia stained brown from bile pigments, thus dif-
treated with iron supplementation. Proper ferentiating it from hookworm eggs, which
sanitation should be installed to prevent are of a similar size.
soil contamination.
Transmission The eggs are not infective until
Treatment is with mebendazole or albenda- they have undergone development in the
zole. (See under hookworm for dosage.) soil for 12 weeks. They require warmth
and moisture to develop and will remain
Surveillance Routine stool investigation of viable in the soil for a considerable period
children admitted to hospital will show a of time awaiting the right conditions.
number of nematode infections. The infective larva goes through stages of
126 Chapter 10
Eggs swallowed
in water or
contaminated food
Eggs passed
in faeces
Development in soil
12 weeks
Fig. 10.1. Ascaris lumbricoides life cycle.
development within the egg casing and if Incubation period 1020 days
swallowed, infection occurs. Eggs are
normally swallowed in polluted water, on Period of communicability From 2 months
vegetables that have been washed with pol- after infection up until about 1 year.
luted water or by swallowing earth directly.
Eggs are passed during indiscriminate Occurrence and distribution Ascaris is a
defecation. very common nematode infection found in
all parts of the world and in all strata of the suggest a diagnosis of tuberculosis. The
society (1000 million people are estimated main effect results from the adult worms
to be infected). Children aged 37 years have attaching to the intestinal wall where they
the highest prevalence. invaginate a piece of mucosa, extracting
blood and nutrients. Anaemia results from
Control and prevention is with personal hy- frank blood loss and depletion of iron re-
giene, food hygiene and proper sanitary fa- serves. The degree of anaemia produced
cilities. The egg is extremely resistant, being depends upon the worm load and one esti-
unaffected by cold, drying and disinfect- mate calculates that 60120 worms (meas-
ants. A temperature of 438C or higher is re- ured by 30 worms excreting 1000 eggs/g
quired to kill them; therefore, any faeces) will result in slight anaemia,
composting process using human excreta whereas over 300 worms (10,000 eggs/g
must maintain this temperature for at least faeces) will cause severe anaemia. The
1 month (Fig. 1.2). newly established worm may produce sev-
eral bleeding points and if the sexes are un-
Treatment is with pyrantel pamoate or balanced, the search for a mate can result in
mebendazole. (See under hookworms for increased activity. These effects will natur-
dosage.) ally be most profound in the growing child
and the pregnant woman. It is the combin-
ation of malaria, malnutrition and other
Surveillance As with Trichuris infection, it
intercurrent infections, in combination
is worth doing routine stool examination on
with hookworms, that accentuate the ser-
children admitted to hospital as any
iousness of this infection.
lessening of the worm burden will improve
health.
Diagnosis Eggs are found in faecal examin-
ation. They are oval and have colourless thin
walls differentiating them from Ascaris,
10.3 Hookworms which has a thick brown exterior (Fig. 9.1).
The eggs of the two species are identical and
Organism Ancylostoma duodenale and only the adults can be differentiated, mainly
Necator americanus cause the two common from their characteristic mouthparts (Fig.
hookworm infections of humans. 10.2).
Clinical features The infective (filariform) Transmission The eggs are passed in the
larvae directly penetrate the skin and mi- faeces and hatch within 2448 h to liberate
grate to a blood vessel or lymphatic vessel an intermediate (rhabditiform) larva. After
from where they are carried in the circula- some days, it moults to produce the infective
tion to the lungs. In the lungs, they break out filariform larva. In suitable conditions of
of the alveoli, find their way up the trachea moist, warm but shaded soil (308C for N.
and enter the gastro-intestinal tract. The americanus and 258C for A. duodenale),
adult stage is finally reached in the duode- this stage of the larva can live for several
num or jejunum, where the male and female months awaiting the opportunity to pene-
worms mate and produce eggs (Fig. 10.2). trate through the skin of a new host. (The
Despite its extensive journey through ingested third stage larvae of Ancylostoma
the human body, like Ascaris, the hook- can also produce infection.) The larva com-
worms are very well adapted to their host monly penetrates the foot of the unshod
and only produce symptoms when heavy person and intense infection can occur
infections occur. The passage through the where areas of beach or bush are demarcated
skin can result in a transient urticaria for defecation purposes. Non-human hook-
(ground itch), while that through the lungs worms can also penetrate the skin and pro-
pneumonitis and haemoptysis. Occasion- duce cutaneous larva migrans (see Section
ally, the haemoptysis can be sufficient to 17.4).
128 Chapter 10
Necator americanus Ancylostoma

duodenale
Larvae pierce skin
Egg
Rhabditiform larva
Filariform larva
810 days
Fig. 10.2. The hookworm life cycle and identification.
Incubation period 810 weeks. distributed, being found extensively

throughout the tropical belt and well north
Period of communicability From about of the Tropic of Cancer in America and the
2 months after infection to up to 5 years; gen- Far East. A. duodenale is found in the Far
erally 1 year. East, the Mediterranean and the Andean
part of South America (Fig. 10.3). It has
Occurrence and distribution N. ameri- been suggested that N. americanus was
canus, despite its name, is the more widely carried from Africa to the Americas as a
, Ancylostoma duodenale.
, Necator americanus,
Fig. 10.3. Distribution of the hookworms.
130 Chapter 10
result of the slave trade. Altogether, some and degree of pathological change and
720 million of the world population have hence the clinical features.
hookworms. An infective filariform larva develops
in warm moist soil, penetrates the skin,
Control and prevention is by use of pit and follows the same internal route as the
latrines or other methods of sanitation. The hookworms to the final resting site in the
wearing of footwear effectively prevents small intestine. However, no eggs are passed
penetration by the larvae. The open sandal to the outside, only rhabditiform larvae are
type of footwear often worn (thongs, flip- found in the faeces. If environmental condi-
flops) is not effective and infection can read- tions are favourable, a free-living cycle takes
ily occur. Mass treatment can be given to place, with the rhabditiform larvae develop-
reduce the parasite load, but without health ing into adults in the soil. This cycle can be
education and the proper use of latrines, it repeated and the number of potential para-
will only produce a temporary improve- sites increases with each completed cycle. If
ment. conditions change, filariform larvae are pro-
duced or if unsuitable for the free-living
Treatment A number of drugs are effective cycle, then the rhabditiform larvae passed
in treatment. Albendazole 400 mg single in the faeces change directly into filariform
dose, mebendazole 500 mg single dose or larvae. Direct autoinfection can also occur,
100 mg twice a day for 3 days, levamisole with the rhabditiform larvae penetrating the
2.5 mg/kg daily for 3 days, oxantel 10 mg/kg intestinal mucosa to enter the blood stream
daily for 3 days or pyrantel pamoate 10 mg/ without ever leaving the body. Swallowed
kg daily for 3 days. The treatment should be larvae can as well complete their develop-
repeated 12 weeks after the previous treatment by entering the body through the intes-
ment. There is concern that resistance tinal mucosa (Fig. 10.4). Achlorhydria, as
could develop as in veterinary practice; occurring in malnutrition, makes infection
therefore, combinations, such as mebenda- easier by the oral route.
zolelevamisole or pyranteloxantel, have It is the abnormal cycle of autoinfection
been advocated. In the debilitated child, that can lead to wandering larvae producing
supporting therapy will need to accompany linear urticaria (larva currens) or eosinophi-
deworming. Iron supplementation, or in the lic lung. Larva currens can persist for
severe case blood transfusion, will be re- periods in excess of 40 years. Immunocom-
quired to treat anaemia. promised persons, such as those with HIV
infection or malignant disease, can get wide-
spread dissemination of worms with serious
Surveillance When mass treatment is
consequences.
planned, an initial survey will delineate
the size of the problem. Follow-up spot
checks of individual stool specimens can Diagnosis is made by finding the rhabditi-
be made to assess progress. form larvae in the faeces or in the aspirate
of the duodenal string test. Serological tests
can be of value, but where positive, repeat
10.4 Strongyloides stool examinations should be made.
Organism The nematode Strongyloides ster- Transmission is from direct penetration

coralis, which is morphologically similar to of the skin by infective stage (filariform)
the hookworms. Far less common is larvae or being swallowed from contamin-
S. fulleborni. ated food, water or fingers. Soil is cont-
aminated by faeces deposited directly on
Clinical features There are several alterna- the ground or inadequately buried.
tive cycles of development and it is the
type of cycle which determines the nature Incubation period 24 weeks.
Infective filariform
larva pierces skin
Rhabditiform
larva passed
in faeces
Free-living
adults in soil
Fig. 10.4. Strongyloides stercoralis life cycles.
Period of communicability Due to autoinfec- Occurrence and distribution Mostly found in

tion and long-living adult worms, once the warm wet tropics, the parasite also
infected, a person can continue to produce occurs in temperate areas. S. fulleborni has
larvae for 3040 years. only been reported from Africa and Papua
132 Chapter 10
New Guinea. Adults, rather than children, Transmission The organism is introduced
manifest the clinical symptoms, either ac- into a wound from soil, dust or animal
quiring the parasite when they were chil- faeces. Cutting the umbilical cord with an
dren or in adult life. unsterile instrument, such as a bamboo
knife, or traditional practice of treating the
Control and prevention All the methods ap- umbilical stump are potent methods of caus-
plicable to the other soil-based nematode ing neonatal tetanus. These can involve
infections are applicable, such as personal covering the stump with an unsterile dress-
hygiene, careful washing and preparation of ing or customary practice of using a cow
vegetables and the wearing of adequate foot- dung or earth poultice.
wear. Soil contamination can be prevented The bacillus is found naturally in the
by good sanitation. soil where it survives in anaerobic condi-
tions. Many types of soils have been found
Treatment is the same as for hookworm in- to harbour C. tetani, but it is more common
fection or any of these treatments can in cultivated soils, especially those
be combined with ivermectin or diethylcar- manured with animal faeces. The organism
bamazine (DEC, see under filariasis, Section is found in horse and cattle dung and less
15.7). commonly in pig, sheep and dog faeces. It is
occasionally found in human excreta, par-
ticularly in people associated with animals.
The vegetative form of the organism is
10.5 Tetanus
sensitive to antibiotics, disinfectants and
heat, but as a spore, it is resistant to all but
Organism The bacillus Clostridium tetani, the super-heated steam of an autoclave.
which is a Gram-positive rod with spherical, Indeed, the spores of C. tetani are used to
terminal spores, giving it a characteristic test the effectiveness of the sterilizing pro-
drum-stick appearance. cess because if it cannot survive, then no
other organism can (apart from anthrax).
Clinical features Infection results from the Spores can survive for considerable
organism entering an abraded surface, such periods of time, but when they enter a
as a cut or scratch. It favours anaerobic con- wound or umbilical stump in which there
ditions, liberating toxin, which produces is a low oxygen reduction potential, they
severe muscle spasms. It is a serious condi- release the vegetative form, which grows
tion in the neonate due to infection of the anaerobically and infection takes place. It
umbilical cord stump. is the moist, contaminated umbilical stump
The adult presents with muscle spasm or the traumatized wound that provides
and rigidity. There may be trismus, in which suitable conditions.
the muscles of the jaw and later the back The replication of the organism is not
become rigid leading to lock jaw and important, but toxin is produced that can
opisthotonos. Muscle spasms can produce have a profound effect out of all proportion
the characteristic half smile, half snarl of to the initial infection. The exotoxin has a
risus sardonicus or generalized opisthoto- high affinity for nervous tissue and as little
nos. These spasms are initiated by external as 0.1 mg is sufficient to kill a person. Toxin
stimuli, such as touch or attempts at intub- is absorbed along the nerves, reaching the
ation, and every care must be taken to pro- spinal cord where the generalized features
tect the patient from such stimuli. Neonatal of the disease are produced.
tetanus generally presents as a difficulty in
sucking; then the rigidity of muscles and Incubation period is from 421 days, but
generalized convulsions develop. It usually most cases occur within 14 days. There is a
commences within 510 days of birth. relationship between incubation period and
severity, with an incubation period of less
Diagnosis is on the clinical presentation. than 9 days having a mortality of 60% and
more than 9 days 25% mortality. This is due children or adults who have not been vac-
to the dose of the toxin. cinated before should be given two doses of
adsorbed tetanus toxoid (0.5 ml), separated
Period of communicability Not transmitted by 4 weeks and a third dose of 1 ml 6 months
from person-to-person directly or indirectly. later. Booster doses every 10 years will
maintain a high level of immunity.
Occurrence and distribution Tetanus occurs In the event of a person being injured
worldwide, with higher rates in Africa, Asia and presenting with a contaminated wound
(especially Southeast) and the Western Pa- that could produce tetanus, the following
cific. Neonatal tetanus is a serious problem action should be taken clean out the
in Africa, especially where birth practices wound, give penicillin, then the following:
are rudimentary. There is an association
with agricultural areas where animal excreta . If the person has been fully vaccinated in
is commonly used for fertilizing the soil, as a the past, a booster dose of toxoid is re-
fuel or as a plaster on the walls of houses. quired only if this is more than 10 years
Domestic animals either share the same ago.
house as their owners or live in such close . If there is no record of tetanus vaccination
proximity that their faeces contaminate the or protection is in doubt, then give the first
surrounding soil. dose of tetanus toxoid plus 250 units of
human tetanus immune globulin or 1500
Control and prevention The aim should units of equine tetanus antitoxin,
always be to prevent tetanus with vaccin- following a test dose. Instruct the person
ation and good hygiene practices, especially to return at 4 weeks and then 6 months to
with the newborn. complete the course of vaccination.
The most effective way of preventing
neonatal tetanus is the vaccination of all Good birth practices are important in pre-
women of childbearing age. The policy is to venting neonatal tetanus and several coun-
give all women a lifetime total of five doses of tries have developed systems for contacting
tetanus toxoid. This is preferable to waiting traditional birth attendants (TBAs) and
until the woman becomes pregnant because giving them courses of instruction. Pre-
many women do not attend antenatal clinic, packed sterilized blades for cutting the cord
especially those who are likely to use trad- can be given and iodine, spirit or similar
itional applications to the umbilical cord antiseptic provided to apply to the cord
stump. The effectiveness of various strat- stump. Where there is no system of TBAs
egies is shown in Fig. 10.5. Women should, but delivery takes place at home with the
therefore, be given their first dose of tetanus assistance of mother or other female
toxoid at first contact or as early as possible relative, then an instruction sheet in the
during pregnancy. The second is given local language can be given to the pregnant
4 weeks later and the third 612 months woman when she attends the antenatal
after the previous dose or during the clinic or at any other contact with the health
next pregnancy. Doses four and five are services. Figure 10.6 illustrates several strat-
given at yearly intervals. Where a woman egies for reducing neonatal tetanus as tried
has a certificate to say that she has received out in rural Haiti.
vaccination as a child, then she only needs to
have two doses during the first pregnancy Treatment Tetanus is a self-limiting disease
and one more before or during the second and if the patient can be kept alive for
pregnancy. 3 weeks, then complete recovery should
Infants are given tetanus toxoid as part take place, but keeping the patient alive
of their childhood vaccination programme for this period of time is the problem. It is
as DTP at 6, 10 and 14 weeks of age. An the toxin that is causing the symptoms
additional booster dose of DTP can be and once this is fixed in the nerves, only
given at 18 months to 4 years of age. School support can be given to the patient to
134 Chapter 10
Schedule
A 3 DPT in infancy
B 3 DPT in infancy and

1 DPT in 2nd year
C As in B plus 1 DT
at school entry
D As in C plus 1 DT
at school leaving
E 2 DT at school
F 3 DT at school
G 5 TT as recommended
by EPI
0 2 4 6 8 10 20 30 40
Age (years)
Fig. 10.5. Expected duration of tetanus immunity after different vaccination schedules. DPT, diphtheria,
pertussis and tetanus; DT, diphtheria and tetanus; TT, tetanus toxoid; EPI, Expanded Programme of
Immunization. (Reproduced by permission of the World Health Organization, Geneva.)
1940 1948 262.21
1949 1955 220.52
1956 1962 136.63
1963 1966 78.54
1967 1968 355
1969 1970 56
1971 1972 07
0 50 100 150 200 250 300

Mortality rates per 1000 live births
Fig. 10.6. Neonatal mortality per 1000 live births in rural Haiti, 19401972, from a retrospective study of
2574 mothers. 1, before national programme for training TBAs; 2, national programme for training TBAs; 3,
hospital treatment for tetanus, training of TBAs by hospital nurse; 4, immunization of pregnant women in
hospital clinics; 5, immunization of women in market places by hospital team; 6, immunization after door-
to-door invitation by community workers. (Reproduced by permission of the World Health Organization,
Geneva.)
maintain respiration, urinary output and be eradicated because C. tetani will always
nutrient intake. The patient is sedated to remain in the environment) as a health
reduce spasms and in all ways, expertly problem by 2005, by intensified vaccination,
nursed. The contaminated wound must be the promotion of clean delivery practices
cleaned and excised, antitoxin or immuno- and a programme of school vaccination.
globulin administered and penicillin given High-risk areas need to be identified from
to kill any remaining organisms. Sadly, the a knowledge of the birth practices, lack
mortality from tetanus is high 40% in of health facilities or preponderance of
adults and 90% in neonates, so the objective cases. All children at school entry should
should always be to try and prevent it. be required to bring their vaccination
certificates with them and if these are
Surveillance WHO has set out to eliminate not adequate, receive a course of tetanus
maternal and neonatal tetanus (it can never toxoid.
11
Diseases of Water Contact
Water is an important medium for the trans- the disease until adulthood. Passing blood
mission of disease processes. Normally it is in the urine is one of the first signs of S.
through drinking water, which has become haematobium disease, but because it is so
polluted by faecal material, that infection is common in the local area, it is generally
transmitted, or through water used to wash ignored, with boys assuming it quite normal
food and the food subsequently consumed. that they should have period bleeding like
It also serves as a medium for fish or other girls do. Infection and egg output increases
organisms to live, which may carry a para- up to about 15 years of age and then de-
sitic stage that is transmitted when they are clines. Individuals vary in their response,
eaten (as covered in Chapters 8 and 9). In with some persons acquiring heavy infec-
this chapter, we look at one important dis- tions and developing severe pathological
ease and one almost eradicated that are changes, while others have only minor
transmitted by contact with water, in symptoms. The more serious manifestations
which the intermediate stages are free are liver fibrosis, portal hypertension and
living. Minimizing water contact is, there- obstructive urinary problems, with the path-
fore, the best method of control if it can be ology depending upon the species of para-
applied. site and the number of eggs deposited in the
tissues. Infections with S. mansoni and S.
japonicum lead to intestinal and liver
11.1 Schistosomiasis damage, while that with S. haematobium
results in bladder complications, including
Organism The main parasites are Schisto- bladder cancer.
soma haematobium, S. mansoni and S.
japonicum. Other species, such as Diagnosis is made by finding the charac-
S. intercalatum and S. mekongi do occur, teristic eggs (Fig. 9.1) of S. haematobium in
but they are only important in well- the urine and those of S. mansoni and S.
defined areas and their epidemiology and japonicum in the faeces or from a rectal
control are similar to one of the three main snip. Urine samples are best collected bet-
types. ween 1100 and 1500 h when egg output is at
a maximum. Leaving the urine to stand, cen-
Clinical features Infection normally starts trifuging it, or passing it through a filter in-
in childhood, with often very little signs of creases the chance of finding eggs. While the
136
Diseases of Water Contact 137
qualitative diagnosis is required in the indi- snail using geotactic and phototactic behav-
vidual case, quantitative estimates are more iour, homing-in on a chemical substance
valuable in epidemiological investigations. miraxone inadvertently liberated by the
In S. haematobium, the simplest method is snail. The miracidium must penetrate a
to pass 10 ml of urine through a filter in a snail within 812 h, but their chance of suc-
Millipore holder. The paper or membrane is cess decreases with age. Some 40% of snails
taken out, dried and stained with ninhydrin are infected at a distance of 5 m in still water,
and the eggs counted directly. Immuno- but where the water is flowing, similar infec-
logical methods, indirect fluorescent anti- tion rates can occur at a far greater distance.
body test (IFAT) and enzyme-linked Normally, infection occurs in water flowing
immunosorbent assay (ELISA) test have at 10 cm/s or less. Even after the rigours of the
also been developed for schistosomiasis, journey when miracidia have entered the
but they only indicate recent or past infec- correct species of snail, many are inactivated
tion, so eggs must be looked for to confirm and only a small proportion develop into
the diagnosis. They are useful in epidemi- sporocysts. This is determined by the part
ological surveys for rapidly defining the of the snail entered and immunity to re-
extent of the infected area. infection developed by the snail (Fig. 11.1).
Pathology is related to the number of Cercariae are stimulated by light to
worms, which can be measured by the emerge from the snail when the ambient
number of eggs produced. In S. haemato- temperature is between 108C and 308C. Cer-
bium, the production of 50 eggs/ml of urine carial emergence increases as daylight pene-
or above is regarded as the level of severe trates the watery environment producing a
pathology and much of present day control peak for S. mansoni at 1200 noon and for S.
strategy is aimed at reducing the egg count haematobium, mid-to-late afternoon. With
below this level. S. japonicum, the stimulus produced by
light is delayed and maximal cercarial liber-
Transmission Infection results from cer- ation occurs at 2300 h. The number of cer-
cariae directly piercing the skin of a person cariae issuing from a snail can be immense,
when they go into the water. On penetrating in the order of 10003000/day, but this
the subcutaneous layer of the host, the cer- depends upon the species and relative size
caria becomes a schistosomule, migrates to of the snail. Where more than one miracid-
the lungs and finally develops into an adult ium has penetrated a snail, there is depres-
in the portal vessels of the liver. Both male sion of cercarial production; this may also
and female worms are required so that occur if the snail is host to other trematode
pairing can take place prior to migration to infections. Cercarial output is greatest in S.
the final destination in the mesenteric or mansoni, less in S. haematobium and least
vesical plexus. Adult worms can live for of all in S. japonicum. Cercariae survive for
2030 years, but are active egg producers 24 h, but their greatest chance of penetrating
for 38 years, although some have produced the host is when they are young. When cer-
viable eggs for over 30 years. The egg output cariae enter within 2 h of release, only 30%
per day in S. haematobium is some 20250, die, but this rises to 50% at 8 h and 85%
in S. mansoni 100300 and in S. japonicum at 24 h.
15003500. It is this massive output of eggs The snail intermediate hosts are species
in S. japonicum that leads to the more rap- specific, Bulinus spp. in S. haematobium,
idly developing and severe pathology. Biomphalaria spp. in S. mansoni and Onco-
Less than 50% of eggs manage to pass melania spp. in S. japonicum. They are il-
through the bladder or intestinal wall to de- lustrated in Fig. 11.1. They can adapt to a
velop further, the remainder being trapped wide range of habitats from natural water-
in the tissue. On reaching water, a tempera- ways to temporary ponds and cultivated rice
ture of 10308C and the presence of light fields. Whenever there is sufficient organic
induce hatching, resulting in miracidia matter on which to feed, snails will be
swimming out. They actively search out a found. Within a body of water, distribution
138

Chapter 11
S. mansoni Bulinus
18.11.2004 5:47am page 138

Oncomelania
S. haematobium Biomphalaria
S. japonicum
Fig. 11.1. Schistosomiasis species and life cycles.

may be quite irregular with dense colonies dividuals and their age, with a few individ-
in some places and complete absence in uals having heavy infections and egg
others. Various factors, which may influ- outputs, while the majority have light infec-
ence snail colonization, are: tions. In areas of high endemicity, children
between 5 and 14 years are responsible for
. Electrolyte concentration. Snails demand over 50% of the contamination. As the infec-
a minimum calcium concentration, tion rate declines, older age groups become
cannot tolerate high salt content or a low more important.
pH. People are infected by collecting water,
. Light is not required by the snail, and they washing (both clothes and the person), in
can often survive in near total darkness. their occupation (such as fishing) or during
. Rainfall may herald the end of the dry recreation. Children are most commonly
season and provide water in which snail infected when they play in water, while in
populations can increase, but if the rain- adults, it is when they carry out their domes-
fall is too heavy, it may flush out the tic duties or occupation. Infection is gener-
snails, resulting in a subsequent decrease. ally due to repeated water contact over
Snail populations, therefore, may follow a a long period of time, but can occur from a
seasonal pattern. single immersion if it coincides with a large
. Temperature rise encourages expansion number of cercariae in the water.
of the population up to a maximum of Animals, such as water buffalo, cattle,
approximately 308C. pigs, dogs, cats and horses, can also serve as
. Density is a limiting factor and results in reservoirs of S. japonicum, but they are
reduced growth. less important than humans as sources of
. Aestivation or the ability of snails to sur- infection.
vive out of the water for weeks or months
allows populations of snails to continue Incubation period 26 weeks.
from one season to another, possibly also
transferring immature infections of S.
haematobium and S. mansoni. The snail Period of communicability 1020 years.
host of S. japonicum can survive condi-
tions of desiccation best of all. Occurrence and distribution S. haemato-
bium and S. mansoni were originally dis-
Snails are capable of self-fertilization, al- eases of Africa, where they are widely
though cross-fertilization is more common. distributed, but with the massive exodus of
Their reproductive capacity is phenomenal slaves that took place in the 17th and 18th
and a single snail can produce a colony centuries, this legacy was carried with
within 40 days and be infective in 60 days. them. The East African slave trade carried
When conditions are optimal, many species S. mansoni to the Arabian peninsula and
of snails will double their population in 23 S. haematobium to the Yemen and Iraq.
weeks. In measuring the age of snail popula- The Western trade was solely in S. mansoni,
tions, size of snails is a useful indicator. A which found a suitable snail host in South
large number of small samples from many America and the Caribbean. S. japonicum
different areas are preferable to a few large probably originated in China, where it has
samples in estimating the numbers and dens- been found in mummified bodies, but is also
ity in water courses. Infection rates in snails found in the Philippines, Taiwan and Sula-
are generally low, with only some 12% of wesi in Indonesia (Fig. 11.2). No cases have
the colony being infective, but even so this been found in Japan since 1978. A separate
level is sufficient to account for high preva- species S. intercalatum, pathogenically
lence rates in the human population. similar to S. mansoni, is found in Congo,
Humans contaminate water either by Cameroon, Central African Republic, Chad,
urinating or defecating into or near water Gabon and Sao Tome. S. mekongi is re-
courses. Egg output is variable between in- stricted to the Mekong River basin in Laos,
140 Chapter 11
S. japonicum.
S. haematobium,
S. mansoni,
Fig. 11.2. Distribution of schistosomiasis.
Thailand and Cambodia. Other localized male technique, but since many snails are
species are S. malayensis in peninsular Ma- hermaphrodite, it is only suitable with
laysia and S. mattheei found in southern Oncomelania.
Africa. Where small and temporary ponds are
foci of infection, they can be drained or
Control and prevention There are two filled (by controlled tipping of household
approaches to the control of schistosomia- refuse). Where canals and irrigation systems
sis: are responsible, concrete lining, increasing
rate of flow and any method to reduce
. reduce the transmission of the parasite; vegetation can discourage snail habitation.
. reduce the level of infection in individ- Unfortunately, these methods are rarely
uals. effective on their own and need to be com-
bined with molluscicides (e.g. niclosamide,
The first attempts to control the parasite, Bayluscide), which can be administered as
while the second aims at minimizing the a liquid, suitable for treating moving water,
pathological effects. The various methods or as granules in lakes and ponds. Continu-
of control are as follows. ous application is required to make a
sustained effect on the snail population. It
REDUCTION OF CONTAMINATION OF THE ENVIRONMENT
has the disadvantage of killing fish and
Humans pollute the environment by urinat- is expensive. Cheaper preparations, such
ing or defecating into bodies of water. This as copper sulphate, are still in limited use
can be minimized by encouraging the use of and naturally occurring plant preparations,
latrines. Unfortunately, it is very difficult to such as Endod (Phytolacca dodecandra),
get everybody in a family or community have shown promise. However, the remark-
to always use a latrine and the few non- able recovery of snail populations once con-
users will be sufficient to maintain a level trol methods are removed and the cost
of pollution (see Section 2.4.2). There is also of molluscicides make snail reduction a
the longevity of the adult worms, meaning less effective approach in schistosomiasis
that prevalence rates will remain static in the control.
community for a considerable period of time.
REDUCTION OF WATER CONTACT Preventing
REDUCTION OF THE SNAIL INTERMEDIATE HOST The water contact can be highly effective in the
snail is a vulnerable link in the life cycle of individual. Various ways of encouraging
the parasite and can be attacked in an effort this are:
to break transmission. The various methods
that can be used are: . health education, especially to school
children, but this is often ineffective
. predators; unless an alternative (e.g. swimming
. biological control; pool), is provided;
. water management and engineering; . providing places to wash have been disap-
. molluscicides. pointingly ineffective for the cost
involved;
Various kinds of fish (particularly Tilapia . where areas of absent or minimal trans-
and Gambusia) are natural predators, but mission occurs in occupational or recre-
they will only reduce snails to a certain ational bodies of water, people can be
level unless they have an alternative source encouraged to use these, rather than the
of food. Snails, especially of the Marisa and heavily infected parts;
Helisoma genera, compete for food supplies . wear rubber boots when wading through
and Marisa will even prey on eggs and water, or if accidental exposure occurs,
juveniles of Biomphalaria. Another ap- then rub vigorously with a towel and
proach to biological control is the sterile apply 70% alcohol;
142 Chapter 11
. drinking water can be treated with iodine somiasis have been tried depending on the
or chlorine or if left to stand for at least resources and nature of the disease as
48 h, cercarial die-off will be complete. follows:
REDUCTION OF HUMAN INFECTION BY MASS CHE- . Raising of economic standards by the pro-
MOTHERAPY With the discovery of effective vision of water supplies and sanitation,
preparations, such as praziquantel, single- environmental engineering and water
dose MDA is now a good method of control. management has been shown to be effect-
A suitable target population is school chil- ive on a long-term basis in countries such
dren between 5 and 15 years of age where as Japan and China.
mass therapy is used. Alternatively, only the . In well-controlled irrigation schemes,
positive cases, or those with heavy infec- mollusciciding on its own may be effect-
tions, are treated following a simple diag- ive. Where discipline and motivation of
nostic procedure. Individual treatment, the population are less certain, a double
based on worm load estimation, aims at dis- approach of mass chemotherapy and re-
ease control by reducing morbidity. It per- duction of water contact is more effective.
mits limited resources to be more widely . When resources are scarce and greatest
spread and attempts the less ambitious benefit for limited finance is required,
target of disease rather than transmission treatment of high worm load cases is the
reduction. method of choice.
The anti-malarial drug artemethur is
also valuable in the control of schistosomia- Surveillance Effectiveness of control strat-
sis and could be used in areas where there is egies can be measured by:
no malaria, such as China, southern Brazil
and Southwest Asia. It can be used in com- . change in incidence rate;
bination with praziquantel. . a shift in peak prevalence to an older age
group;
REDUCTION OF THE ANIMAL RESERVOIR Animal . reduction in geometric mean egg output;
reservoirs are responsible for maintaining . greater awareness of socio-economic
S. japonicum. In order of importance they values (e.g. the use of water supplies and
are dogs, cows, pigs, rats and water buffa- sanitation facilities).
loes. As most of these are domestic animals,
proper animal management can reduce con-
tamination of the environment. Vaccination
of domestic animals could be done. Baboons 11.2 Guinea Worm
and monkeys have been shown to be reser-
voirs of S. mansoni and could play a part Dracunculus medinensis, the largest of the
in maintaining infection. There is little pro- nematode worms to attack humans, used to
spect of controlling these animals. be a serious problem in India, Pakistan,
southern Iran, most of West Africa, South-
VACCINATION There are difficulties in pre- west Asia and Sudan, infecting some 80 mil-
paring a vaccine because the schistosome is lion people. It is spread by spilt-water
able to absorb host antigen and mask its washing larvae back into an unprotected
presence, but three vaccines are currently well or by infected people using walk-in
under trial for S. mansoni. wells. WHO launched an eradication pro-
gramme to make all wells safe with a sur-
STRATEGIES FOR SCHISTOSOMIASIS CONTROL Var- rounding wall and concrete apron so as to
ious approaches for the control of schisto- prevent all spilt-water from washing back
into the well. Walk-in wells were converted Sudan, where control was hampered by
into lift-wells or alternative water supplies the continuing war, while most of the rest
provided. By these simple strategies, were in Ghana, Nigeria and Mali.
Dracunculus infection has been eradicated This has been the most successful eradica-
from most of the area. In 2003, there were tion programme to use such a simple
32,193 cases; 63% of these cases were in strategy.
12
Skin Infections
The skin is a common site for several children. Illness commences with fever
communicable diseases, presenting with followed by a characteristic skin rash of
rashes of various kinds. Infection is often macules, papules, vesicles, pustules and
transmitted from one person to another dried crusts. The lesions occur in groups,
directly by skin contact or by other means, appearing over several days, so pox of differ-
especially the airborne route. Control is by ent stages will be seen at the same time. In
the avoidance of contact with infected chickenpox, the rash is distributed cen-
individuals and where available the use of trally, appearing on the chest and abdomen
vaccines. and sparsely on the feet and hands.
Some skin infections, tropical ulcers The majority of people contract the
and those due to scabies and lice have been disease in childhood when it is an incon-
covered in Chapter 7 as they share common venience rather than a life-threatening con-
methods of control. Typhoid often has an dition, but if this has not occurred and if
accompanying skin rash, but is more appro- they subsequently develop the illness as
priately covered with other faecaloral adults, it can be very serious. This is a par-
diseases in Chapter 8. Meningococcal men- ticular problem in island and isolated com-
ingitis often presents with a petechial rash munities where varicella can be a fatal
and is covered in Chapter 13. Many of the disease in the elderly. Pregnant women,
arbovirus diseases present with skin rashes, who contract the disease in late pregnancy
but as their method of transmission is by or shortly after delivery, are at risk of severe
vectors, they are covered in Chapters 15 generalized chickenpox with a 30% mortal-
and 16. ity. Neonates who develop chickenpox
within 10 days of birth are liable to a serious
generalized infection. Chickenpox in early
pregnancy may result in congenital malfor-
12.1 Chickenpox/Shingles (Varicella) mations. Death results from generalized
viraemia, pneumonia, haemorrhagic com-
Organism Herpesvirus varicella-zoster virus plications, encephalitis or cardiomyopathy.
(VZV). The virus remains latent in the body,
lodged in nerve bundles, and in later life,
Clinical features A generally mild disease, especially during a debilitating disease
chickenpox is a common infection of (such as HIV infection), the identical virus
144
Skin Infections 145
(VZV) causes shingles. This presents as age, who have not had chickenpox as a
a vesicular rash with erythema in a well- child, and the immunocompromised. There
defined area of skin supplied by the affected is a risk in using vaccination by shifting
dorsal root ganglia. Pain and paraesthesia the age of developing naturally acquired
occur along the course of the affected nerve. chickenpox to older age groups where the
disease is more serious, making it unlikely
Diagnosis is on clinical criteria, especially to become part of the routine childhood
the central distribution of the rash and the vaccination programme.
presence of lesions at different stages, differ-
entiating it from smallpox. Any case of a pox Treatment Acyclovir and vidarabine can be
rash that dies or has an unusual distribution used to treat adults, children with serious
should be a smallpox suspect (see Section disease and older persons with shingles.
18.2). Human varicella-zoster immunoglobulin
(VZIG) is available in some centres and can
Transmission The infection is transmitted by be used within 10 days of exposure for con-
fluid from the vesicles. This can occur in the tacts liable to develop severe disease, such
pharynx before the main rash, when trans- as pregnant women, neonates and the
mission is by droplets; otherwise, the spread immunosuppressed.
occurs by direct skin contact, airborne dis-
persion of vesicle fluid or through articles Surveillance Outbreaks should be reported
soiled by discharges. so that susceptible individuals can be pro-
tected and given vaccination if available.
Incubation period varies from 2 to 3 Any suspect case of smallpox must be
weeks. reported to WHO.
Period of communicability is from 3 days

before the onset of the rash to 6 days after 12.2 Measles
its first appearance.
Organism Measles is a member of the Para-
Occurrence and distribution Chickenpox myxoviridae family of viruses.
occurs worldwide in an epidemic form
often spreading serially (Section 2.2) from Clinical features Measles normally com-
one place to another. It is a disease of chil- mences with a prodromal fever, cough, con-
dren in the temperate regions, but is more junctivitis and small spots (Kopliks spots)
commonly found in adults in the tropics. most easily seen inside the mouth. The char-
acteristic blotchy rash begins on the third to
Control and prevention One attack of seventh day of the illness, generally on the
chickenpox confers life-long immunity; so face, but soon spreads to the whole body.
it is preferable for children to have the dis- In developing countries, it is a serious
ease rather than be protected and run the disease and accounts for a considerable
risk of developing it as adults. Special amount of mortality and morbidity in the
groups, such as neonates, pregnant women childhood population. It particularly has a
and the sick, should be protected by pre- severe effect on the nutritional status of the
venting cases of chickenpox from coming child, resulting in the healthy child losing
into contact with them. In hospital, cases of weight and the malnourished child becom-
chickenpox should be isolated from other ing critically ill. The peak of infection is
patients. between 1 and 2 years of age, at the very
A live, attenuated varicella virus vac- time when breast milk alone is an inad-
cine has been developed, but is not widely equate source of food supply and weaning
available. It is useful for vaccinating high- foods may not yet have been introduced.
risk groups, such as women of childbearing The association of nutritional change and
146 Chapter 12
measles can be, and often is, a lethal com- Diagnosis is on clinical criteria, but measles
bination. IgM can be found in the saliva with im-
There are a number of reasons for the munological tests.
nutritional depletion produced by measles.
Any disease process puts extra demands on Transmission Although the main feature of
the body, increasing catabolism. Fever and measles is the skin rash, it is transmitted by
the desquamation of all epithelial surfaces the airborne route from nasal and pharyn-
demands protein replacement, which is geal secretions. This can be by articles con-
handicapped by a sore mouth, often second- taminated with secretions such as cloth or
arily infected by Candida, thus preventing clothing used to wipe a running nose as well
the child from sucking properly so that even as by respiratory droplets produced in a
breast milk is not taken. Then from the other coughing bout.
end, diarrhoea, which is such a common Measles is the most contagious of all
feature of measles in developing countries, infectious diseases and no age is spared. In
discharges the body reserves further. Per- the Fijian outbreak in the 1870s, adults
haps the greatest weight loss is due to im- as well as children succumbed, affecting
munosuppression, much of which takes families as a whole at the same time, causing
place after the child has recovered from the deprivation and starvation that resulted in a
acute attack. high death rate. Now adults have experi-
The disease process attacks all epithe- enced measles as children, with the age
lial surfaces, producing most of its compli- of infection getting younger. This is ex-
cations in the respiratory tract. Pneumonia plained by greater contact of communities
is the commonest complication, while lar- due to improvement of communication,
yngo-tracheo-bronchitis is serious, with a while the intense social contact at a very
high mortality. Acute respiratory infections young age (babies carried on their mothers
(see Section 13.1) are one of the leading back) gives maximum opportunity for early
causes of childhood ill health and the seque- transmissions.
lae of measles are responsible for a large
component of this problem. If the acute
pneumonia does not kill, the damage done
makes the child more susceptible to further
attacks of respiratory infection when the Period of communicability From 1 day before
measles has long gone. the first signs of infection until 4 days after
The effects on the eye can cause blind- the rash starts (or 4 days before to 4 days
ness. Corneal lesions result from epithelial after the rash begins).
damage, which can lead to ulceration, sec-
ondary infection and scarring. In severe Occurrence and distribution Measles has
cases, perforation or total disorganization been a severe infection in Western countries
of the eye can occur. These severe effects for a considerable period of time, producing
only result if there is concomitant vitamin mortality in poor and slum populations
A deficiency, so giving vitamin A to all similar to what is seen in developing coun-
measles cases is effective. Measles by its tries. Introduced with European explor-
nutritional and direct effects has been ation, it caused devastating epidemics,
regarded as the most important cause of particularly in island communities, some
blindness in a number of tropical countries. of which never recovered their former popu-
Measles is an important cause of otitis lation numbers. However, in many develop-
media. It can also result in encephalitis, ing countries in which it is a major problem,
either in the acute form or a late slow-onset there is evidence that measles has been
sclerosing panencephalitis, which is always present for several hundred years, with the
fatal. pattern having changed from sporadic
Skin Infections 147
epidemics with all ages involved to one of tions of high infectivity, such as during
endemicity in which the under-5-year-olds an epidemic, admission to hospital or refu-
are predominantly affected. gee camp or if the infant has HIV infec-
tion, then reducing the age of vaccination
Control and prevention of measles is by to 6 months is justified. In this case, another
vaccination. As measles is such an infec- vaccination should be given at 1215
tious disease, it can be reckoned that every months.
child will develop it. Some 10% will either In developed countries, vaccination
have such a mild infection or be partially is given at 1215 months so that the time
protected by maternal antibodies as to taken to reduce the incidence in the popula-
appear not to have been infected. A further tion will be less, as shown in Fig. 12.1. The
1020% will not have measles until the greater the coverage the more rapidly this
following year due to the epidemic effect; is achieved. For example, 60% coverage
therefore, the expected number of cases of will theoretically take 12 years to reduce
measles can be calculated from the birth rate the incidence to zero if vaccination is given
minus 25%. If the birth rate in a developing at 12 months, but never be achieved at 9
country is 50,000, then 75% of this means months. However, 70% coverage will
that 37.5 cases of measles per 1000 can be achieve zero incidence with vaccination
expected each year, which represents given at 9 months, which is being achieved
37,500 cases in an administrative unit of a by an increasing number of developing
million people. Calculations like these can countries.
be used to estimate the number of children Effective measles vaccination coverage
to be vaccinated and hence the vaccine re- will not only reduce the number of children
quirements. developing the disease in an epidemic, but
Eighty per cent of susceptibles will will have the secondary benefit of raising the
need to be vaccinated to produce control of age of developing the disease, as can be seen
the disease, but a lower target may be accept- in Fig. 12.2. Epidemics had occurred in
able in more isolated communities. This Namanyere, Tanzania, regularly every
target will need to be achieved every year second year until 1978 when there was
in rural areas, but as much as every 6 months only a minor increase, the main epidemic
in urban areas. Measles vaccine is 90% ef- being delayed until 1979. This meant that
fective if the cold chain is not broken. children born in 1977, who could have
Maternal antibodies protect the new- expected to become infected in their second
born infant for the first 6 months of life, but year of life (1978), had their measles put off
thereafter the child becomes readily suscep- until 1979 when they were beyond the age of
tible to infection with a peak around 1 year. maximum mortality.
The seroconversion rate is some 76% at The chances of a susceptible child de-
the age of 6 months, 88% at 9 months and veloping measles when admitted to hospital
100% at 12 months. Giving measles vaccin- is very high as it is already sick with another
ation at 1 year would produce the best con- complaint. It is fortunate that measles vac-
version, but, by this time in developing cine can produce protective immunity
countries some 50% of the population quicker than the wild virus (about 8 days
would have already had the disease. Giving for the vaccine and 10 days for the disease),
it at 6 months will be before all but a so as long as the child is vaccinated within
few have had the disease, however the ser- 48 h of admission, it will be protected.
oconversion rate is so poor at this time that Because of the severity of disease in the
not many will be protected. The best com- debilitated child, there are very few contra-
promise is a first vaccination at 9 months, indications and the malnourished and those
with the possibility of a second opportunity with minor infection should all be vaccin-
through periodic mass campaigns. In condi- ated. HIV infection is not a contraindication
148 Chapter 12
100
(a) Vaccination at 9 months

Percentage of initial incidence level
80
Coverage
30%
60
40%
40
50%
20
60%
70%
0
0 5 10 15 20 25 30
Years
100
(b) Vaccination at 12 months

Percentage of initial incidence level
80
Coverage
60
30%
40%
40
50%
20
60%
70%
0
0 5 10 15 20 25 30
Years
Fig. 12.1. The relative impact of immunization programmes on measles incidence in the age group 019
years, according to age at vaccination and population coverage. (Reproduced by permission from Cvetanovic,
B., Grab, B. and Dixon, H. (1982) Bulletin of the World Health Organization, 60(3), 405422.)
as the child is more likely to die from in South and Central America, give a
measles than from complications of receiv- second measles vaccination using vaccin-
ing a live vaccine. ation days or special campaigns. Countries
The policy in many countries is to give a of the western hemisphere have set a target
second measles vaccination at 45 years or for the cessation of measles transmission by
on school entry. Other countries, especially 2007.
Skin Infections 149
70
Vaccinations started
No. measles epidemics 60
50
40
30
20
10
0
1972 1973 1974 1975 1976 1977 1978 1979 1980
Year
Fig. 12.2. Prolongation of the time interval between measles epidemics due to vaccination in Namanyere,
Tanzania.
As vaccination coverage is increasing, a needs to be determined to work out the best

potential problem could arise because less time to supplement routine vaccination pro-
maternal antibody is produced by mothers grammes. If measles cases are focal, then this
who have acquired their immunity from may indicate gaps in vaccination coverage
vaccination rather than by having measles. (Fig. 3.2). Since all children should be vac-
This means that infants of a younger age will cinated, an estimate of vaccine coverage can
become susceptible, so vaccination may be made by comparing the number of new
need to be given earlier if coverage is not vaccinations with the number of children
complete. born.
Measles vaccine is conveniently com-
bined with rubella (MR) or both with rubella
and mumps (MMR). Despite adverse publi- 12.3 Rubella
city given to the MMR vaccine, no compli-
cations have been confirmed and the Organism Rubella virus, a member of the
vaccine should continue to be used. Togaviridae family of viruses.
Treatment There is no specific treatment, Clinical features Infection in the adult

but supportive therapy with fluids and is generally mild, presenting with a maculo-
easily digested foods needs to be given. Vita- papular rash of short duration, fever, con-
min A supplementation should be given to junctivitis and cervical lymphadenopathy.
all children with measles. Complications Some 2050% of the infections are sub-
may require additional treatment, such as clinical. However, if the woman is pregnant,
antibiotics for bacterial chest infections. especially in the first 10 weeks of pregnancy,
her developing fetus will suffer from
Surveillance All cases of measles should be congenital rubella syndrome (CRS). The
recorded and monthly totals charted to indi- congenital defects are more severe if the
cate epidemics and estimate when new epi- infection is acquired earlier in pregnancy,
demics will occur (Fig. 12.2). Measles has a resulting in stillbirth in the first few weeks.
seasonal pattern, which can vary markedly Otherwise a range of congenital defects
from country to country (Fig. 1.7); so this can result, including cataracts, glaucoma,
150 Chapter 12
deafness, heart defects and microcephaly. rubella or to vaccinate all children aged
Milder defects will develop between the 915 months as part of the routine child-
11th and the 16th weeks and after the hood vaccination programme. If the vaccin-
20th week of pregnancy, there is no further ation programme is considered sufficiently
risk. efficient to embark on the latter strategy,
then an extra campaign to target all women
Diagnosis is by detecting IgM from serum or and girls over 12 years of age should be run
saliva and is important if infection in a preg- at the same time for the first few years of
nant woman is suspected. introducing rubella vaccination.
If a policy of childhood vaccination is
Transmission The virus is transmitted adopted, then rubella vaccine is best admin-
in droplets from the nasopharynx by the istered with measles vaccine as MR or in
airborne route or direct contact. Most infec- combination with measles and mumps as
tions are acquired from children and adults MMR (see Sections 12.2 and 12.4).
during an outbreak, but infants with CRS
can produce virus from pharyngeal secre- Surveillance An estimate of the level of CRS
tions and urine for up to 1 year so are a can be obtained from hospital records and
potent source of infection. MCH records of deaf and blind infants.
Measles vaccination records and numbers
Incubation period 1520 days. of cases of measles are good indicators of
the efficiency of the childhood vaccination
programme in deciding which strategy of
Period of communicability From 7 days
rubella vaccination to introduce.
before the onset of the rash to 4 days after.
CRS infants continue to shed virus for up to
12 months.
12.4 Mumps
Occurrence and distribution Worldwide dis-
tribution, but the importance of rubella in Organism Mumps virus is a member of the
developing countries has not been appreci- Paramyxoviridae family of viruses.
ated until comparatively recently. It occurs
in an epidemic form probably due to the Clinical features Mumps is not a true skin
number of susceptibles in the population, infection, but is included here as it shares
with children becoming infected when common means of control with measles and
they are 28 years of age in urban areas and rubella. It is an infection of the salivary
612 years in rural areas. glands producing enlargement and pain in
the parotid gland, but can lead to orchitis,
Control and prevention The objective is to mastitis, meningitis, pancreatitis and acute
prevent CRS by vaccination of children and respiratory symptoms (see Section 13.1).
adults. Although adolescent girls and Commonly an infection of children 25
women of childbearing age are the target years of age, the more serious manifestations
population, just vaccination of this group are more likely in adults, especially males.
will never eliminate rubella; therefore, all
children of both sexes should ideally be vac- Diagnosis is made on clinical grounds, but
cinated. However, if the vaccination pro- serological confirmation can be made with
gramme is far from complete, the effect will mumps-specific IgM, a rise in IgG or culture
be to postpone the age of infection to older of saliva or urine.
and more dangerous ages in women likely to
become pregnant. Developing countries, Transmission The virus is transmitted via
therefore, need to decide between protecting direct contact or by droplets spread by the
adolescent girls and women of childbearing airborne route. Any contact of saliva, such as
age only, with no attempt to eliminate sharing of cutlery, wiping the mouth with a
Skin Infections 151
common cloth, or kissing, can result in erysipelas or scarlet fever. Pyoderma and
transmission. impetigo are superficial skin infections
with vesicles, pustules and crusts. Erysip-
Incubation period 1424 days. elas is a red, tender, oedematous cellulitis
of the infected part of the body, originating
Period of communicability 6 days before to 6 from the point of infection. Scarlet fever
days after the start of parotitis. presents as a generalized rash that blanches
on pressure with high fever, strawberry
Occurrence and distribution Mumps is prob- tongue and flushing of the cheeks. In some
ably more common than assumed to be with cases, there is an appreciable mortality
up to 85% of the population found to have or else it can result in otitis media, glomer-
been infected in adult life, although few ulonephritis or acute rheumatic fever
would have manifested the disease. With (ARF, Section 13.10). Although not a skin
such a high proportion of the population infection, streptococci can also cause puer-
meeting the virus, there is a relatively high peral fever due to post-delivery infection of
risk of complications and costbenefit stud- the female genital tract.
ies have shown that vaccination produces
substantial economic savings. Diagnosis Culture of the organism from
the point of infection or pharynx on blood
Control and prevention The reason for in- agar.
cluding mumps in the routine childhood
vaccination programme is similar to that Transmission is mainly by the respiratory
for rubella (Section 12.3). Where there is an route or direct contact with the lesion or
efficient programme with the majority of skin (in impetigo). Flies can transfer the or-
children being vaccinated, it is advanta- ganism and are a major means of infecting
geous to include it with measles and rubella scratches and wounds in tropical countries.
as the MMR vaccine. However, if less than The organism can be carried in the nose,
75% of children are vaccinated, then this pharynx, anus and vagina or in chronic
could result in an epidemiological shift to skin lesions, and is an important cause of
older age groups, increasing the likelihood hospital infections.
of complications. If mumps vaccination is
included, then a second opportunity, either Incubation period 13 days.
by the routine programme or by catch-up
campaigns, should be given unless coverage Period of communicability 1021 days or
is over 90%. until a chronic infection has been treated.
Surveillance Comparing the number of chil- Occurrence and distribution Worldwide,

dren born with those who complete their predominantly in children, but scarlet
childhood vaccinations or are vaccinated fever is more common in temperate regions.
against measles will give an estimate of the Infected skin lesions either due to strepto-
efficiency of the vaccination programme cocci or staphylococci are very common in
and whether mumps vaccination should be tropical regions.
added.
Control and prevention Treat all cases
promptly and dress infected lesions in a
12.5 Streptococcal Skin Infections sterile manner. Any person with an infected
lesion should not be involved in operations
Organism Streptococcus pyogenes, group A. or hospital duties until healed. Personal hy-
giene, especially the washing of hands after
Clinical features Streptococcal infections of defecation, and the discouragement of nose-
the skin can present as pyoderma, impetigo, picking should be advocated. Use of proper
152 Chapter 12
latrines and the control of flies are long-term disease respond in different ways to the
preventive measures. challenge.
The generation time from inoculation to
Treatment Benzathine penicillin G intra- multiplication of a stable number of M.
muscular, or penicillin G or V orally. leprae is only 1824 days, but the develop-
ment of the disease will take anything from 7
Surveillance Scarlet fever and puerperal months to in excess of 7 years (mean 36
fever are notifiable diseases in some coun- years). The first lesion is described as inde-
tries. terminate (Fig. 12.3) because at this early
stage, it is impossible to decide to which
place in the spectrum of disease it will
develop. There is either a single ill-defined,
12.6 Leprosy slightly hypopigmented macule, commonly
seen on the face, trunk or exterior surfaces,
Organism Mycobacterium leprae. or there may be a small anaesthetic patch.
The lesion will then develop into a leproma-
Clinical features Leprosy illustrates the tous or tuberculoid type or oscillate in the
conflict between the infecting organism transitional state of borderline leprosy
and the host more dramatically than any between these two extremes.
other disease. M. leprae is widespread in Lepromatous leprosy (LL) reflects the
the environment, yet only a small propor- complete breakdown of the hosts immune
tion of people ever show clinical symptoms responses and the maximum infection
of the disease and those few who do get the with M. leprae. In the early stages, the signs
Bacillary index Cell-mediated immunity
Level of
instability
Lepromatous Borderline Tuberculoid

LL BL BB BT TT
Indeterminate
Fig. 12.3. The spectrum of leprosy illustrating the proportion of bacilli, the cell-mediated immune response
and the level of instability, in the different forms of the disease.
Skin Infections 153
of the disease may be very few, but a skin light touch. A skin smear in TT is nearly
smear will reveal large numbers of mycobac- always free of bacilli (pauci-bacillary), so
teria (multi-bacillary). Early signs that the diagnosis depends upon the detection
have been described, but rarely observed, of nerve damage.
are oedema of the legs and nasal symptoms Borderline leprosy, as its name sug-
of stuffiness, crust formation and blood- gests, is on the border between the two ex-
stained discharge. These are unlikely to tremes of LL and TT. True borderline (BB) is
be recognized as leprosy and it is generally uncommon, with the disease tending to pro-
not until the more obvious skin lesions gress to either the lepromatous (BL) or tuber-
become apparent that the diagnosis is culoid (BT) part of the spectrum. Signs,
made. therefore, vary between the two extremes
Leprosy lesions favour the cooler parts with features of each, but predominating in
of the body, so the buttocks, trunk, exposed one or the other. Borderline leprosy is
limbs and face are the more likely sites. common, but its instability leads to reaction
Lesions may be macules, papules or and nerve damage, which can often be
nodules, with or without a colour change severe.
and often show lack of sweating when the Where the host response is adequate
patient becomes hot. The signs of nerve and cell-mediated immunity high, the dis-
damage do not appear until much later in ease tends towards the tuberculoid end of
LL, with a concurrent thickening of the the spectrum, where it is low to LL. Simul-
skin of the forehead, loss of eyebrows and taneous HIV infection will shift the host re-
damage to the cartilage of the nose. The eyes sponse from the tuberculoid towards the
are also attacked with an infiltrative kera- lepromatous. Otherwise the host response
titis, iritis and eventually leads to blindness. can vary over the course of the illness pro-
Tuberculoid leprosy (TT) is at the op- ducing reactions, which can either be up-
posite end of the spectrum, showing the full grading (towards TT) or downgrading
response of cell-mediated immunity to the (towards LL). These are type 1 reactions.
attacking organism (Fig. 12.3). M. leprae has The nearer the case is to the centre of the
a predilection for nervous tissue and it spectrum, the more severe is the reaction.
is within this nervous tissue that the cell- Type 1 reactions may affect all tissues, skin
mediated response takes place, causing and nerves only or produce a generalized
early damage to the nerves. The tuberculoid systemic reaction.
patient, therefore, tends to present early A different type of reaction (type 2) is
with signs of weakness or loss of sensation. found in lepromatous and borderline lepro-
Palpation of the nerves will often demon- matous cases and is associated with massive
strate a thickening with loss of sensation or destruction of bacilli. Immune complexes
motor power in the distribution of the are formed in the tissues and these lead to
affected nerve. The ulna nerve, as it bends an increased reaction in existing lesions.
over the medial epicondyle at the elbow, or The characteristic finding is erythema nodo-
the lateral popliteal nerve, where it curves sum leprosum, which appears on the skin as
round the neck of the fibula, are good places painful red nodules commonly on the face
to palpate nerves for thickening. Dermal and exterior surfaces.
lesions are not raised, often appearing as
apparently normal areas of the skin, lacking Diagnosis A skin smear is made from
sensation or sweating when the patient every suspected case of leprosy, collecting
exercises. Occasionally though, they are dermal tissue without drawing blood.
well-defined and scaly with raised edges, A negative smear does not mean that a case
but quite different from the succulent is not leprosy as tuberculoid cases rarely
macules and papules of LL. Loss of sensa- have mycobacteria. Smears are stained
tion should be elicited with a pin as well as with ZiehlNeelsen stain and the number
154 Chapter 12
of mycobacteria counted, giving the bacter- over 80% of school children in Uganda, but
ial index: only 40% of children under 5 years of age in
Myanmar.
6 Over 1000 bacilli in an average field
Leprosy can occur in an epidemic as
5 1001000 bacilli in an average field well as an endemic pattern, but due to the
4 10100 bacilli in an average field incredibly protracted life history of the dis-
3 110 bacilli in an average field ease, the epidemic form is rarely seen.
2 110 bacilli in 10 fields Between 1921 and 1925, there was an epi-
1 110 bacilli in 100 fields demic in the Pacific island of Nauru, with
30% of the population becoming infected
and the disease was notably non-focal. All
Mycobacteria can also be obtained from
ages were susceptible and most people de-
nasal scrapings of the inferior turbinate.
veloped tuberculoid (BTTT) leprosy,
A skin biopsy is taken from tuberculoid
which healed spontaneously.
and borderline patients or a nerve biopsy
It has been estimated that as much as
where there is no skin lesion.
5% of people are susceptible to LL and con-
tact with a lepromatous case increases the
Transmission The method of transmission
risk of infection. Children and young adults
has not been conclusively demonstrated,
are more commonly affected, but the chil-
but several factors, such as prolonged close
dren of leprosy patients do not develop LL
contact, the finding of large numbers of ba-
any more frequently than the general popu-
cilli in the nasal discharges of lepromatous
lation. It would seem that leprosy is very
cases and in the skin, suggest that both
similar to tuberculosis in that the organism
airborne and direct skin contact are import-
is more common than assumed to be, asymp-
ant. M. leprae have been found to survive
tomatic infections may occur, but only
from 2 to 7 days outside the body in nasal
those who are susceptible will develop the
secretions. Individuals vary in their suscep-
disease.
tibility and it is possible that repeated doses
Due to active control measures and
of bacilli or a large infective dose are re-
multiple drug therapy, there has been a
quired to produce the disease.
marked reduction of leprosy in the world,
with a global prevalence of one case in a
Incubation period 120 years. population of 10,000 in 2001. Among 122
countries considered endemic in 1985,
Period of communicability Possibly 1 month 107 have achieved elimination and leprosy
to 2030 years. Treatment with rifampicin remains a public health problem only
renders the patient non-infectious after 3 in Angola, Brazil, Central African Republic,
days. Congo, Cote dIvoire, Guinea, India, Liberia,
Niger, Madagascar, Mozambique, Myanmar,
Occurrence and distribution Leprosy is Nepal, Paraguay and Tanzania. It is dimin-
found mainly in the tropical regions of ishing as a disease burden in India,
the world, with poor socio-economic condi- Brazil, Myanmar, Madagascar, Nepal and
tions probably being a major factor. LL Mozambique.
is more common in Asia and TT more
common in Africa. This differing suscepti- Control and prevention The immediate
bility might help to explain the response of control is a reduction of the leprosy reser-
the peoples of these two continents to BCG. voir by case finding, treatment and follow-
BCG, given at birth, can produce a hypersen- up, especially those with the lepromatous
sitivity and change the cell-mediated im- form of the disease. A small proportion of
munity from negative to positive, but some cases will present themselves, but active
people appear to have no natural immunity search must be made for others concentrat-
and remain always susceptible to the lepro- ing on selective groups. School children
matous form of the disease. BCG protected should receive priority, as they are likely to
Skin Infections 155
contain a quarter of all cases and a higher mine has the advantage of being anti-
proportion of new ones. Also contacts of inflammatory as well as bacteriostatic, and,
any case should be examined at frequent therefore, can be used in the treatment of
intervals, as leprosy is more common in reactions at a dose of 100 mg three times a
those people who have prolonged contact week. Steroids and thalidomide are also
with a leprosy case. All new cases are useful in the treatment of reactions.
treated by multiple drug therapy (see Part of any leprosy programme is the
below). development of a rehabilitation service.
BCG vaccination induces hypersensi- This not only encourages leprosy patients
tivity and increased resistance to develop- to present themselves for treatment, but
ing leprosy in some ethnic groups and helps them to return as participating
is valuable in the prevention of leprosy members of the community. Much can be
as well as tuberculosis (Section 13.1). done from limited resources, such as making
M. leprae-based vaccines are under trial in sandals out of old tyres and pieces of wood.
several countries with promising results. The elements of rehabilitation are to protect
The long-term reduction of disease will re- anaesthetic limbs, actively treat sores and
quire an improvement in general hygiene, ulcers and provide support (including sur-
better housing and less overcrowding. gery) to restore function. The eyes are also
damaged in leprosy and, supportive treat-
Treatment is determined by the bacterial ment can do much to prevent blindness
index of the case. from developing.
. High-risk (multi-bacillary) LL and BL Surveillance Dedicated leprosy field workers

cases: A three-drug regime consisting of have been found to be of considerable value
rifampicin 600 mg once a month super- in detecting new cases and following up
vised, dapsone 100 mg daily self-adminis- cases under treatment, otherwise a system
tered, clofazamine 300 mg once a month within the existing health service should
supervised, then 50 mg daily self-admin- be developed. Combining leprosy and
istered. Treatment should be continued tuberculosis surveillance is economically
for a minimum of 12 months. useful.
. Non-bacillary cases BT or TT: Rifampicin Initially whole populations should
600 mg once a month supervised, plus be screened in areas of high endemicity,
dapsone 100 mg daily self-administered, then concentration made on examining
for 6 months or six monthly doses within school children and all contacts of cases.
a 9-month period. All cases should be registered, often
managed as a combined programme with
All patients with positive skin smears at tuberculosis. Section 13.1 on follow-up
the start of treatment should have repeat and registration is equally applicable to
skin smears at 6 and 12 months. Clofaza- both diseases.
13
Respiratory Diseases and Other Airborne
Transmitted Infections
The vulnerable respiratory apparatus is between human beings is a necessary part of

easily invaded by microorganisms. Breath- life, control becomes more difficult and
ing is continuous and as respiratory gases non-specific. Even so, the respiratory dis-
are wafted in and out, infecting organisms eases are an enigma, the voluminous quan-
find free passage deep inside the body. The tities of expelled organisms are sufficient to
site of entry is commonly the nasopharynx, infect the entire population, yet only some
but entry can also occur through the oro- individuals manifest disease. It is the infect-
pharynx and the conjunctiva. The lachrymal ive dose and the host response, which deter-
glands drain into the nasopharynx and ex- mines whether infection will occur.
perimental studies have shown that this is Environmental factors that increase the in-
often a more certain method of infection fective dose (e.g. overcrowding) or reduce
than directly through the nose. The respira- the host resistance (e.g. malnutrition or con-
tory system also includes connections to the comitant infections) can have a marked
middle ear, the sinuses and the gastro-intes- effect.
tinal tract. This chapter includes airborne trans-
The ciliated lining and mucus-secreting mitted infections that present as diseases of
cells of the respiratory tract can act as non- the respiratory system and also includes dis-
specific host defence mechanisms entrap- eases of other systems of the body that are
ping microorganisms and passing them to transmitted by the airborne route. Most of
the exterior. In attempting to expel these the skin infections, covered in Chapter 12,
secretions from the body by coughing or are also transmitted mainly by the airborne
spitting, organisms may be transmitted to route.
another host. The lymphoid tissues, espe-
cially the tonsils and adenoids, guard the
respiratory apparatus, but sometimes may 13.1 Tuberculosis
themselves become foci of infection.
Respiratory infections are usually trans- One of the major diseases in the world, tu-
mitted by direct contact between individ- berculosis poses considerable challenge in
uals and generally the closer the contact, developing countries. Not only are a pro-
the greater the chance of spread. As contact portion of the population infected with this
156
Respiratory Diseases and Other Airborne Transmitted Infections 157
debilitating and often fatal disease, but the ment, pleural effusion or cavity formation.
period of infectiousness is prolonged (ap- The third phase of the disease results from
proximately 5 years in an untreated case), complications of the regional nodes. These
permitting transmission to many other per- may be obstructive, leading to collapse and
sons. Indeed, in a number of countries, an consolidation, cause erosion and bronchial
endemic balance has been achieved destruction or spread locally. The final stage
whereby the number of cases that resolve is one of blood stream spread, disseminating
spontaneously, are cured by medical treat- bacilli to all parts of the body where they
ment or die, are replaced by an equal may produce tuberculous meningitis or mil-
number of new cases entering the pool of iary infection. Long-term complications are
tuberculosis. HIV infection has added to those of bones, joints, renal tract, skin and
the likelihood of people developing tuber- many other rare sites. These features are il-
culosis so that it is increasing in sub- lustrated in Fig. 13.1.
Saharan Africa. In the world, 8 million The risk of developing local and dis-
people develop tuberculosis every year and seminated lesions decreases over a period
2 million die from it. of 2 years. If the majority of cases are going
to progress, they will do so within 12
Organism Mycobacterium tuberculosis, but months of infection or 6 months from the
infection can also be caused by M. bovis development of the primary complex. By
(from cattle) or M. africanum. There are the end of 2 years, 90% of the complications
many mycobacteria occurring naturally, would have occurred. Bone and other late
including M. avium, M. intracellulare complications are a very small proportion
and M. scrofulaceum, that can sensitize beyond this time.
the individual and interfere with BCG
vaccination. In endemic countries, M. tuber- Diagnosis Tuberculosis is spread by droplet
culosis is widespread, with 13% of infection, so sputum-positive cases transmit
the population per year being at risk of the disease much more efficiently than those
infection. whose sputum is negative on microscopy.
The risk to the community is, therefore,
Clinical features A productive cough with from pulmonary tuberculosis and the em-
weight loss, fever and anaemia are the phasis should be on finding these cases by
most important signs of tuberculosis. Any taking a sputum smear, ideally confirmed
chronic cough persisting for 3 weeks or by culture. The comparative costs of diag-
more, especially if there is also weight loss nostic techniques are:
and anaemia, should be regarded as a pos-
sible case of tuberculosis and sputum smears
taken. Haemoptysis is an important diagnos- Smear 0.02
Culture 0.20
tic sign and may be streaking of the sputum
Sensitivity 0.40
with blood or frank coughing-up of fresh Full plate X-ray 1.00
blood.
Tuberculosis infects people in a spec-
trum of severity depending on the host re- Fifty sputum smears can be made for the
sponse, the dose of organisms and the length equivalent cost of one X-ray and this econ-
of time. The first sign of infection is the omy can be used for diagnosing cases in the
primary complex in which the organism is community. Anybody presenting to the
localized to an area of the lung with a corres- health services with a cough for 3 weeks or
ponding enlargement of the hilar lymph more should be asked to produce some
nodes. In the majority of people, this heals sputum and a smear made. This is dried and
completely or with a residual scar, and the stained with ZiehlNeelsen for acid-fast ba-
person develops immunity to further chal- cilli. X-ray examination has a high sensitiv-
lenge. If healing does not occur, then the ity and, therefore, is of more value in
focus extends to cause glandular enlarge- countries with a low incidence and plentiful
158
4

2
1
Bloodstream dissemination
Meningitis or miliary
Complications of regional
nodes
Extension of the focus Bronchial erosion
Pleural effusion or (incidence decreases with Late complications
Infection cavitation increasing age) renal and skin
(25% of cases (most after 5 years)
Primary complex occur within 9 months,
(majority of cases heal) 75% within 12)
Chapter 13
Bone and joint (most
Fever of onset
within 3 years)
1 early infection, especially in first year of life

Resistance (reduced by 2 malnutrition
Acquired 3 intercurrent infections, e.g. measles, pertussis
18.11.2004 5:48am page 158

48 weeks 3 months 6 months 12 months 24 months
Tuberculin- Risk of local and disseminated lesions Decreasing risk 90% within first 2 years
sensitive
Fig. 13.1. The evolution of untreated primary tuberculosis (modified). (Reproduced by permission from Miller, F.J.W. (1982) Tuberculosis in Children, Churchill
Livingstone, Edinburgh.)
resources, but sputum microbiology is still . malnutrition;

necessary to confirm the diagnosis and pro- . intercurrent infections, such as measles,
vide cultures for drug susceptibility testing. whooping cough and streptococcal infec-
A simpler form of search is made in the tion;
village of a newly diagnosed case. The con- . HIV infection;
tacts are examined to see if there is anybody . occupations or environments that damage
with a productive cough or clinical signs, the lung (mining, dust, smoke).
and a smear made. Contacts should be
given BCG. Chemoprophylaxis is given to As well as variation amongst individuals,
children under 6 years and to contacts posi- there are also considerable differences in
tive for HIV, and followed up at regular the susceptibility of populations. This can
intervals. This can all be included in the be measured by the annual tuberculosis in-
national registration system. fection rate, which compares the tuberculin
reaction of non-vaccinated subjects of the
Transmission is by the airborne route, with same age every 5 years. With BCG vaccin-
coughing and spitting being the main modes ation at birth, this cannot be done any
of disseminating the organism. Many people longer, but data obtained before this became
meet the tubercle bacillus in early life, ac- a universal policy is still valid. Another
quire resistance and are quite unaware of method of estimating incidence is from tu-
ever having come into contact with it. A berculosis notifications as seen in Fig. 13.2.
proportion, approximately 5%, will mani- There are also environmental factors
fest the disease in varying levels of severity. and density is as important as susceptibility
It might be nothing more than an enlarge- of the population. The dose of bacilli that
ment of the primary focus with a few sys- the individual will meet is increased by con-
temic effects, only to resolve spontaneously, tinued contact over a period of time. This
while others may have respiratory symp- dose/time factor is more likely to be found
toms or progress rapidly to blood stream in conditions of poverty and overcrowding.
spread presenting as a case of miliary or If the dose is sufficiently large and main-
tuberculous meningitis. The type and sever- tained for long enough, even the defences
ity of the disease is determined by the host of the immunologically competent individ-
response, but why one person should de- ual may be broken down.
velop tuberculosis, and another should not, The risk of infection is greatest in
cannot generally be determined. There is the young and rises again in the old, so over-
some evidence that susceptibility may be crowding increases the opportunity for
genetically determined as people who have infection to be acquired at a younger age.
suffered from tuberculosis, even if ad- Since the young mix extensively, they
equately cured, are more likely to develop a will have a greater opportunity for passing
new infection a second time. Some families on infection. At the other end of life, the
are particularly susceptible, as with the elderly often form persistent foci in a com-
famous literary family the Bronte sisters, munity, a potent source of infection to the
where first the mother died from tubercu- young.
losis, followed by nearly all the children, HIV infection has changed the epidemi-
yet the father never succumbed to the dis- ology and presentation of tuberculosis,
ease. The dose of bacilli might also be im- especially in Africa, leading to more lower
portant because young children in close lobe and extrapulmonary disease. (There
contact with an active case more commonly are estimated to be more than 20 million per-
develop severe tuberculosis (miliary or men- sons worldwide with dual tuberculosis and
ingitis). Factors that are known to reduce HIV, with the majority of these cases in
resistance are: Africa.) Reduced host response has in-
creased susceptibility and allowed reactiva-
. young age, especially the first year of life; tion or reinfection to take place as well as
. pregnancy; increasing the likelihood of new infection
160

Chapter 13
18.11.2004 5:48am page 160

The designations employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the
World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers
or boundaries, Dashed lines represent approximate border lines for which there may not yet be full agreement.
Fig. 13.2. Tuberculosis notification rates, 2002. Reproduced by permission of the World Health Organization, Geneva.
from a contact or case; however, there is lence are defined as those where less than
evidence to suggest that HIV/tuberculosis 10% of children under 15 years have a posi-
patients are less infectious. Conversely, tu- tive tuberculin test. These are largely the
berculosis patients are more likely to rapidly countries of Western Europe and North
progress to full-blown acquired immuno- America. Tuberculosis, however, is increas-
deficiency syndrome (AIDS) when infected ing in Eastern Europe and the former USSR.
with the HIV virus. Initially HIV-infected Nearly the whole of the tropical world has a
tuberculosis patients commonly present high prevalence rate with some countries
with pulmonary infection similar to the HIV experiencing over 50% of the under 15-
negative case, but as the disease progresses, year-olds being tuberculin-positive. In add-
extrapulmonary tuberculosis predominates ition, urban areas have higher prevalence
and other manifestations of HIV disease, rates than rural areas. The rates are high in
such as chronic diarrhoea, generalized Africa and parts of South America. Asia,
lymphadenopathy, oral thrush and Kaposis India, Myanmar, Thailand and Indonesia
sarcoma, are more common. All HIV-positive all have high tuberculin-positive rates. In
cases should, therefore, be investigated the Americas, the indigenous peoples have
for tuberculosis and all tuberculosis cases a much higher rate than the non-indigenous.
tested for HIV. Despite the increase in extra- There is a high susceptibility in Pacific
pulmonary tuberculosis, it is still the Islands in which tuberculosis was an un-
sputum-positive case that is responsible for known disease until the arrival of explorers,
transmission of infection and this must who introduced the disease.
remain the priority in searching for cases.
Consumption of unpasteurized milk Control and prevention There are four main
may result in bovine tuberculosis in humans strategies for the control and prevention of
where the disease is present in the animal tuberculosis in the following order of prior-
population. This presents with enlargement ity:
and suppuration of the cervical lymph
nodes rather than pulmonary disease. It is . search and contact tracing for new cases;
now less common than before with the . adequate treatment of all cases, especially
testing of cattle and pasteurization of milk, the sputum-positive;
but in developing countries where cattle and . improvement of social and living condi-
their produce are an important part of the tions;
diet, such as in Central and South America, . BCG vaccination.
bovine tuberculosis is found.
Vaccination by BCG induces cell-mediated
Incubation period The period between infec- immunity to the mycobacteria and does not
tion and development of the primary com- generate humoral immunity, as do other
plex is 412 weeks. vaccines. BCG vaccination, therefore, alerts
the bodys defences rather than inducing
Period of communicability A new, untreated antibody formation. After a BCG vaccination
case of tuberculosis will normally produce a primary infection will still take place, but
organisms for 1218 months, but in those the progressive or disseminated infection
that develop a low-grade infection with will be reduced.
chronic cough, infection can continue Effectiveness of BCG varies consider-
for a considerable period of time (about ably in different countries in Europe,
5 years). Once treatment has started, the there is a good response, while in India, it
person becomes non-infectious in about is marginal. This is thought to be due to
2 weeks. atypical mycobacteria circulating in the en-
vironment and, therefore, BCG should be
Occurrence and distribution Tuberculosis is given at birth in developing countries or as
found worldwide (Fig. 13.2) in various soon after as possible. School entry or 1014
levels of severity. Countries of low preva- years is the main age for giving BCG in
162 Chapter 13
developed countries, while it is likely that Tuberculosis is particularly a disease of

some developed countries will move to a poor social conditions and overcrowding as
selective vaccination policy giving BCG shown by the remarkable decline of the in-
only to high-risk groups, such as immi- fection from industrialized countries prior
grants. BCG should be administered to all to the advent of chemotherapy. The disease
infants, including those born to mothers was as bad, if not worse in Europe, at the
with HIV infection. It should not, however, turn of the century than in many developing
be given to those with symptomatic HIV or countries now, but showed a progressive
pregnant women. and continuous reduction of cases as living
BCG is a freeze-dried vaccine given conditions improved. As standards in-
intra-dermally. Other methods, such as creased, there was a demand for improved
multiple puncture, jet injection or scarifica- housing with less people sharing the same
tion, have been found to be not so satisfac- room so that overcrowding declined. Per-
tory. The vaccine is sensitive to heat sonal hygiene improved and such practices
and light and, therefore, must be carefully as spitting disappeared almost completely
protected. (see Fig. 13.3).
Sputum smear examination is a very
simple technique for screening populations,
Treatment and prophylaxis The functions of
especially where there has recently been a
chemotherapy can be summarized as
case of tuberculosis. All contacts of a case
follows:
should have several sputum smears taken,
concentrating on the young and elderly. If a
contact has not been vaccinated, then they . treatment of individual cases to reduce
should be given BCG. Close contacts under 6 morbidity and mortality;
years of age and HIV-positive persons should . reduce the number and period of infec-
be given prophylaxis, unless they are sus- tious cases;
pected of having disease in which case they . provide a method of disease reduc-
should be given treatment. tion in developing countries where the
90,000
80,000
70,000
Specific chemotheraphy became available
60,000
Notifications
50,000
40,000
30,000
20,000
10,000 Total
Male
Female
1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980
Year
Fig. 13.3. The decline of tuberculosis in England and Wales 19121975. (From DHSS (1977) Annual Report of
the Chief Medical Officer, Department of Health and Social Security for 1976, Her Majestys Stationary Office,
London. Crown copyright, reproduced with the permission of the Controller of HMSO.)
raising of social standards would take patient is cured, the Central Registry is noti-
some time to achieve; fied. Reminders and double checks can be
. prevent the emergence of resistant strains. built into the system, such as the central
registry sending out quarterly checks on
All treatment should be directly observed each patient.
therapy (DOT) to ensure compliance. A
newly diagnosed case of tuberculosis The sophistication of the system depends
should be treated with a four-drug regimen upon the resources of the country, but lack
for 2 months consisting of the following: of resources is never an excuse not to have a
system at all. To not follow-up a partially
treated patient is a waste of expensive hos-
Isoniazid 300 mg daily pital treatment, encourages the develop-
Rifampicin 10 mg/kg up to 600 mg daily ment of resistant organisms and increases
Pyrazinamide 35 mg/kg up to 2 g daily the risk to the community. Follow-up is
Ethambutol 25 mg/kg daily or streptomycin always cheaper than re-diagnosis and treat-
15 mg/kg daily ment.
Evaluation of the tuberculosis control
programmes is primarily by cohort analysis
This is followed by isoniazid and rifampicin in which the proportion of new smear-posi-
taken daily or three times weekly, for a fur- tive cases that are cured or are certified to
ther 4 months. If the taking of treatment have completed the treatment, but no smear
cannot be directly observed, then isoniazid done, is measured. The WHO target is 85%.
plus ethambutol taken daily should be used Other useful indicators are:
instead and given for a period of 6 months.
Treatment should continue for 912 months . annual rate of new tuberculosis cases
in those cases of miliary, tuberculosis men- diagnosed;
ingitis or bone/joint disease. . rate of sputum-positive cases diagnosed;
Prophylaxis with isoniazid can be given . proportion of children under 5 years of
to close contacts under 35 years of age and to age diagnosed;
babies (5 mg/kg) born to mothers, who de- . proportion of miliary and meningeal tu-
velop tuberculosis shortly before or after berculosis;
delivery. . rate of sputum smears examined;
. rate of BCG scars, on survey;
Surveillance A system to follow-up all diag- . relapse rate;
nosed cases of tuberculosis discharged from . rate lost to follow-up.
hospital or health centre is required on the
following lines: A decrease in the proportion of children
under 5 years of age diagnosed and those
1. Register the case with a central registry with miliary and meningeal tuberculosis
on diagnosis. will indicate improvement. However, this
2. When the patient is discharged, inform will need to be confirmed by a sputum
the registry, the nearest clinic to the persons smear survey. Nursing staff should be taught
home and the supervising doctor. to always give the BCG vaccination in the
3. The clinic ensures the patient receives same place, normally the deltoid area or lat-
regular follow-up treatment or goes and eral forearm below the elbow of the left arm,
finds them if they default. so that touring staff, school teachers, etc. can
4. The supervising doctor visits on a regular rapidly examine a group of children.
basis to check the clinical records and make The WHO DOTs strategy is summar-
sure that the registered patients are receiv- ized as:
ing treatment.
5. When the full course of treatment is com- . political commitment;
pleted and the doctor is satisfied that the . secure drug supply;
164 Chapter 13
. diagnosis by smear microscopy of passive because no prior contact with the new vari-
case-finding; ant has been made.
. treatment with rifampicin containing
DOT for 68 months; Clinical features ARIs are divided into upper
. cohort analysis. and lower ARIs, the former producing a run-
ning nose, sneezing and headache, while the
main symptoms of lower respiratory tract
13.2 Acute Respiratory Infections (ARI) infection are cough, shortness of breath and
inward drawing of the bony structure of the
lower chest wall during inspiration, which
The acute respiratory infections (ARI) are
is called chest indrawing. Both are generally
the commonest causes of ill health in
accompanied by fever. The main patho-
the world. WHO have estimated that there
logical feature is pneumonia, which can
are 1415 million deaths a year in children
either be lobar or bronchial. In lobar pneu-
under 5 years of age and one-third of these
monia, one or more well-defined lobes of the
are due to ARI, yet despite their importance,
lung are involved, whereas in bronchial
they are a poorly defined group of diseases.
pneumonia the condition is widespread.
They include the common cold, influenza,
The causes of pneumonia are listed in
pneumonia, bronchitis and a number of
Table 13.1.
other infections. They can be separated by
clinical criteria, but it is the differing re-
sponse of the individual to the organism Diagnosis Identifying the organism by cul-
that determines the clinical severity and ture of the sputum can be attempted where
management. A mild infection from an facilities permit, but in most developing
upper respiratory tract infection in one countries, ARI will be diagnosed on
person may develop in another to a life- clinical criteria.
threatening attack of pneumonia. It is, there-
fore, not only the organism that determines Transmission is by coughing out a large
the disease, but also the patients response number of organisms in a fine aerosol of
to the organism. droplets, which are either breathed in,
enter via the conjunctiva or are swallowed
Organisms A number of different organisms from fingers or utensils. Susceptibility and
have been implicated including Streptococ- response are determined by host factors,
cus pneumoniae, Haemophilus influenzae, some of which are listed below:
Mycoplasma pneumoniae, influenza, rhino-
viruses, adenoviruses, metapneumovirus 1. Age. Young children develop obstructive
and respiratory syncytial virus (RSV). diseases, such as croup (laryngo-tracheo-
Viruses are of a wide range, with each bronchitis) and bronchiolitis. Tonsillitis is
species having a number of serotypes, commonest in school age, whereas influ-
with new ones appearing from time to time. enza and pneumonia are important causes
However, the most important cause is of death in the elderly. In young children,
S. pneumoniae or the pneumococcus or mortality is inversely related to age.
H. influenzae. The host defends him or her- 2. Portal of entry. Volunteers have been
self by producing an appropriate immune more easily infected by some organisms ap-
response, but because of the large number plied to the conjunctiva than through the
of serotypes, it is a continuous process. In- nasopharynx.
fection will cause illness in some people, 3. Nutrition. Low birth weight and mal-
but not in others who have developed an nourished children have a higher morbidity
immune response to the specific organism and mortality. Certain nutritional deficien-
or an antigenically similar serotype. New cies, such as deficiencies of vitamin A and
antigenic mutations, as occur in influenza, zinc, contribute to the development of a
can cause epidemic or pandemic spread more severe disease and higher death rate.
Breast-feeding appears to have a protective tions and the active administration of anti-
effect. biotics to the severe case. The mild infection
4. Socio-economic. ARI is a disease of pov- is best treated at home and kept away from
erty with higher incidence in lower socio- sources of other infection, which may cause
economic groups and those that live in more serious disease, while the severe case
urban slums. Higher rates of lower respira- requires early treatment to prevent compli-
tory disease have been found with increas- cations and death. In children, the respira-
ing family size. Much of the reason for this tory rate and chest indrawing are used to
increase appears to be due to increased con- decide management:
tact and agglomeration as shown by children
attending day care facilities or school where . Mild cases, with a respiratory rate of less
infection occurs irrespective of social class. than 40 breaths/min in children of age
5. Air pollution. A correlation with domes- 212 months and 50 breaths/min in the
tic air pollution has been shown in South children of age 15 years, are treated at
Africa and Nepal. Passive smoking may home with supportive therapy. The
affect pulmonary function and make the mother should be encouraged to nurse
child more susceptible to infection as well her child, giving it plenty of fluids
as influence the child to become a smoker. (breast-feeding or from a cup), regular
6. Climate. More respiratory infections are feeding, cleaning the nose, maintaining it
found in the cooler parts of the world or in at a comfortable temperature and avoiding
the higher altitude regions of the tropics. contact with others.
There is a distinct seasonal effect in many . Moderate cases, with a respiratory rate of
countries, with more respiratory infections over 40 breaths/min in under-1-year-olds
in the winter. However, cold alone is not a and 50 breaths/min in children 15 years
causative factor. Cold derives its name old, but with no chest indrawing, should
from the belief that becoming chilled or be given antibiotics (oral cotrimoxazole
standing in a draught is responsible, but (4 mg/kg twice daily), oral amoxycillin
when volunteers are subjected to these (15 mg/kg three times a day) or intramus-
stresses and inoculated with rhinoviruses, cular penicillin G) and nursed at home.
they develop no more colds than controls. . Severe cases, with chest indrawing, cyan-
7. Other infections. Any infection, which osis or too sick to feed, must be admitted
causes damage to the respiratory mucosa, as in-patients and given active support as
will allow a mild infecting organism to pro- well as treatment with antibiotics.
gress to more serious consequences. The
most important of these diseases is measles, Control and prevention The first step in
with post-measles pneumonia being par- management of a child with ARI is to separ-
ticularly common. ate the mild from the moderate and to treat
the moderate and severe. The essence is
Incubation period This varies with the or- speed and active treatment. This can easily
ganism, but in most cases is 13 days. be taught at the primary health care level.
The mother can be educated on the manage-
ment of her child with a mild infection and
Period of communicability Variable; for the
when to refer. It is the delay in referral and
entire period of any respiratory symptoms.
treatment that will allow a moderate case to
become severe and the severe to die.
Occurrence and distribution Worldwide, the The village health worker can identify
most important cause of death in children in and treat the mild or moderate case of ARI
developing countries. using simple diagnostic criteria and a stand-
ard treatment protocol. Measuring the res-
Treatment The first line of action is to assess piratory rate and knowing which action
the severity of illness and give treatment. to take are the most important aspects.
This is supportive therapy for mild infec- Training and supervision of primary health
166 Chapter 13
care workers is a priority in the management nectomized children and the immuno-
of ARI. deficient. However, the new conjugate
Preventive actions that can be under- pneumococcal vaccine shows promise in
taken are listed below: children under 2 years of age and is likely
to be included in childhood vaccination
. Reduce contact. ARIs are just as common programmes if sufficient supplies can be
in industrialized countries as they are in made available. Vaccines against RSV,
developing countries, but infant deaths parainfluenza and the adenoviruses are
from respiratory infections in the former in preparation.
have declined. The reason would appear
to be due to smaller families and greater Surveillance Measles generally occurs as
birth intervals, permitting increased indi- seasonal epidemics, which can be fore-
vidual care of children and better nutri- casted and top-up vaccination given
tion. The child is reared at home and does (Section 12.2). Influenza is normally pan-
not need to be carried round where it is demic with warning given of strain of organ-
exposed at a very young age to infecting ism and vaccine composition, allowing
organisms. sufficient time for persons at risk to be
. Good nutrition. Well-nourished children protected.
are in a stronger position to defend them-
selves against any infection. Encourage
breast-feeding, especially during early
13.3 Influenza
stages of illness. Providing additional nu-
tritional support to children with measles
can prevent them developing post- Organism There are three types of influenza
measles pneumonia. viruses A, B and C with H antigen (15 sub-
. Health education. Teach people to cough types) and N antigen (9 subtypes), so that
away from others, cover the mouth when the virus is designated as H1N1, H1N2, . . . ,
coughing, not to spit or smoke and pro- H3N2. In addition, the site of isolation,
vide proper ventilation for smoke and culture number and year of isolation are
fumes. used (e.g. A/Beijing/262/95) (H1N1). So
. Vaccination of childhood infections. The far a major antigenic shift to H4 or N3 in
danger of developing pneumonia after human infection has not yet occurred. Anti-
measles is a serious problem, so preven- genic drift in both A and B viruses, produ-
tion of measles will reduce the severe cing new strains occurs at infrequent
forms of ARI. Indeed, measles vaccination intervals and is responsible for most epi-
is perhaps the single most effective demics.
preventive method (Section 12.2). Vaccin-
ation for H. influenzae is now recom- Clinical features Influenza presents with
mended by WHO in routine childhood fever, malaise, muscle aches and upper res-
immunization programmes. Pertussis, piratory symptoms of sudden onset. There is
diphtheria and BCG vaccination should initially a dry cough, which can sometimes
also be encouraged. be severe and often leads to secondary infec-
. Other vaccines. Influenza vaccine is pre- tion, with the production of sputum. It is a
pared annually according to the expected serious infection in the elderly with high
strain of influenza and should be given to death rates. When a major antigenic shift
those at risk (e.g. immunocompromised occurs as it did in 1918, all ages are suscep-
and those with chronic respiratory infec- tible and the number of deaths can be enor-
tions) if facilities allow. The polysacchar- mous (an estimated 50 million).
ide pneumococcal vaccine is not
recommended in routine childhood vac- Diagnosis is on clinical grounds taking care
cination programmes, but could be used to differentiate influenza (occurring season-
in special circumstances, such as for sple- ally or in epidemics) from other causes of
respiratory infections, especially the Influenza vaccine is available for pro-

common cold. Direct immunofluorescence tecting at-risk persons, such as people over
(DIF) or virus isolation from throat or nasal 65 years of age, those with chronic chest or
swabs can be made in specialist centres. kidney disease and the immunocomprom-
ised. The difficulty of producing a vaccine
Transmission is via the airborne route is that a new one has to be produced each
through sneezing or coughing, but can also year, containing the expected composition of
be by direct contact with mucus. Influenza is antigenic sub-units. The WHO collaboration
highly infectious and spreads throughout centres, with reference laboratories through-
whole communities, potentiated by over- out the world, provide advance warning to
crowding and frequent social contact, such assist countries in producing vaccine, but
as at the work place. new techniques, such as virus manipulation
Influenza also occurs in birds and pigs to anticipate natural change in the virus,
and these may well be the reservoir from could allow banks of virus to be kept in store.
which human infection originates. The
close association of humans with domestic Surveillance Sentinel reporting centres with
birds and animals, particularly in South an agreed case definition probably provide a
China, is thought to be how new variants better idea of the influenza situation than
arise. collecting data of variable quality from
every clinic and hospital. This can be com-
Incubation period 15 days with a mean of 2 pared with laboratory-confirmed cases
days. where facilities permit. WHO reports on
the global situation in the Weekly Epidemi-
Period of communicability 2 days before ological Record (WER) from a worldwide
onset of symptoms to 5 days after. network of reporting centres.
Occurrence and distribution Influenza A is

responsible for pandemics and regular sea-
13.4 Whooping Cough (Pertussis)
sonal outbreaks, B for smaller localized out-
breaks and C produces mild infections. In
the tropics, epidemics tend to occur in the Organism Bordetella pertussis. B. paraper-
rainy season, while in temperate climates, tussis produces a milder disease.
influenza is nearly always a disease of the
winter months. Pandemics have occurred in Clinical features Illness commences with
1889, 1918, 1957, 1968 and 1977. upper respiratory symptoms, fever and
cough, which becomes paroxysmal with
Control and prevention As influenza is the characteristic whoop, or sometimes
highly infectious, the majority of the popu- ends in vomiting. The classic whooping
lation becomes infected during an epidemic, disease is not seen in children under 3
but any reduction of social contact, particu- months of age, when instead, they have
larly in crowded places, can reduce this like- attacks of cyanosis and stop breathing.
lihood. Spitting should be outlawed and Whooping cough is a serious disease if it
people encouraged not to cough directly at occurs at a young age, the severity being
people. The wearing of masks, as practised inversely proportional to age. A mild infec-
in China and Japan, is probably more effect- tion in the older child, it becomes an import-
ive in preventing spread from an infected ant cause of death in the very young.
person wearing a mask than in protecting
the non-infected. Once the cloth mask be- Diagnosis is mainly on clinical criteria,
comes damp through exhaled breath, it but culture of the organism from a nose or
ceases to be effective, but tight-fitting throat swab can be attempted, although the
masks with changeable filters should offer organism is difficult to grow. Serology is
reasonable protection. useful.
168 Chapter 13
Transmission is via airborne spread of drop- Fluid loss is an important cause of mortality
lets particularly during the early stage of so mothers should be encouraged to give
illness. Older children and adults may extra fluids and breast-feed immediately
have such a mild infection that their import- after a coughing bout.
ance as a source of infection is not realized.
Vaccinated individuals can have sub- Surveillance In many countries, whooping
clinical infection in which organisms are cough is a notifiable disease.
disseminated.

13.5 Diphtheria
Period of communicability 4 weeks from the
first symptoms, being most infectious in the Organism Corynebacterium diphtheriae and
first week, before the paroxysms start. rarely C. ulcerans.
Occurrence and distribution Whooping Clinical features Diphtheria produces both

cough is a serious disease in tropical coun- local and systemic effects. The organism
tries contributing to high rates of infant can infect the tonsils, pharynx, larynx,
mortality. Vaccination programmes have nose or skin, forming a pale grey membrane
markedly reduced the disease in the temper- and local inflammation. Symptoms are
ate regions of the world, but where the vac- fever, sore throat and enlarged cervical
cination programme has decreased or been lymph nodes in the pharyngeal form,
abandoned, it has rapidly returned as a blood-stained discharge in the nasal form
major health problem. and skin ulcers in the cutaneous form. The
Where the young infant is always inflammatory reaction produced in the re-
carried around by its mother, there is an spiratory tract can lead to swelling of the
increased opportunity for exposure, coming neck and respiratory obstruction. From the
into close contact with other children who primary site, exotoxin is produced, which
might be infectious. can cause myocarditis or neuropathy, espe-
cially cranial nerve palsies.
Control and prevention Isolation of cases, es-
pecially of young children and infants, Diagnosis Throat, nose or skin swab of the
should be instituted. Infective children exudate. A culture of the organism should be
should be kept away from school, markets sent to a reference laboratory if possible.
and any place where young children are
likely to congregate. Known contacts of a Transmission Diphtheria can be transmitted
case of whooping cough (e.g. in the by:
extended family of a case) should be given
a booster vaccination if they have been vac- . airborne transmission of droplets;
cinated before, otherwise they should re- . direct contact with lesions and exudates;
ceive prophylactic erythromycin and . indirect through articles soiled with dis-
vaccine. charges;
The median age for the disease is 2 . ingestion of contaminated milk.
years, but because of its severity, vaccin-
ation should be started at 12 months. In an unimmunized population, there is a
Three doses of vaccine are given, normally high incidence of carriers and a low inci-
combined with tetanus and diphtheria as dence of cases in a ratio of approximately
triple vaccine. 19:1. Between 6% and 40% of children are
infected every year so that by 5 years, some
Treatment Erythromycin is only effective 75% have been infected and by 15 years,
when given in the first week of the disease. nearly all the children are infected. This
means that by 15 years of age, the majority of test dose for hypersensitivity. Erythromycin
children have developed immunity either or procaine penicillin G should be used for
by a sub-clinical infection or one in which specific treatment.
clinical symptoms were revealed.
Surveillance Diphtheria is a notifiable dis-
Incubation period 25 days. ease in most countries.
Period of communicability About 2 weeks.

13.6 Meningococcal Meningitis
Occurrence and distribution Commonly a
disease of children, diphtheria can occur in Organism Neisseria meningitidis. Many ser-
non-immunized adults with serious results. ogroups and sub-groups have been identi-
Outbreaks of the disease are seen, but it is fied, but of these A, B, C and Y are the most
probably a much more frequent disease than important in producing disease, while A
realised, as sub-clinical transmission and C predominate in epidemics. W135 has
through skin and possibly nasal lesions, recently been responsible for some out-
maintains immunity. This was probably breaks.
the situation in many tropical countries,
but now universal childhood vaccination Clinical features Fever, headache, vomiting,
programmes are protecting young children. neck stiffness and progressive loss of con-
A breakdown of these programmes, or sciousness. A petechial rash, which does
remaining pockets of unvaccinated adults, not blanch, is an important sign. Infants
leads to serious disease. show floppiness and high-pitched crying,
while children may present with convul-
Control and prevention Diphtheria is pre- sions.
vented by vaccination of all children with
three doses of diphtheria toxoid. This is Diagnosis is by lumbar puncture, but should
normally combined with pertussis and tet- not delay early treatment, which can be
anus as triple vaccine commencing in the given straight away and lumbar puncture
first or second month of life. Ideally, a done afterwards if necessary. A Gram stain
booster dose should be given at 18 months is only reliable in some 50% of cases, so
to 4 years of age. As with polio and rubella culture should be attempted wherever pos-
vaccination, diphtheria immunization sible and sensitivity obtained. Blood should
shifts the likelihood of disease to an older also be taken for culture and polymerase
and more dangerous age so complete cover- chain reaction (PCR). Smears from petechiae
age of all children is imperative. Adults can also be examined by Gram stain.
visiting an endemic country from one in
which the vaccination status is good, should Transmission is by airborne spread of drop-
have an adult-type booster (adult Td) in lets and from direct contact with secretions
which the concentration of the toxoid is re- from the nose or throat. The organism is
duced. Ideally, adults, particularly travel- found commonly in the nasopharynx so
lers, should have booster doses of adult Td other factors must also be responsible for
every 10 years. meningitis to occur.
In the event of an outbreak, previously Epidemic meningitis was first studied
vaccinated contacts should be given tetanus in cooler climates and an association found
and diphtheria toxoids and those not vac- with overcrowding, especially in military
cinated the toxoid and an antibiotic (ery- institutions. The organism when introduced
thromycin or penicillin). into an overcrowded environment produced
both cases and carriers (nasal). As the
Treatment If diphtheria antitoxin is avail- number of carriers increased, the number
able, it should be given to cases following a of cases of meningitis did so likewise.
170 Chapter 13
However, in the African (Sahel) epidemic native explanation is that transmission is

form, the heat makes people spend much of directly from the nose through the skull
their time out of doors and overcrowding is and any traumatic insult to the nasal
not a phenomenon at this time of year (Fig. mucosa, such as the intense drying out
13.4). Although overcrowding seems to in- during the Sahel hot season, or upper res-
crease the number of carriers and the poten- piratory tract infection in colder climates,
tial for more cases, it does not explain the potentiates a greater number of organisms
mechanism for causing meningitis. to pass along these minute channels and
The organism inhabits the nasal mucosa overcome the defences of the meninges.
within which it is anatomically very close to
the meninges, although separated by for- Incubation period 210 days.
midable barriers of bone and membrane.
The generally accepted theory is that the
Period of communicability Once effective
organism passes from this site into the
treatment has started, the patient ceases to
blood stream, crosses the bloodbrain bar-
be infective within 24 h, but any carrier will
rier and enters the cerebrospinal fluid (CSF).
continue to produce organisms for between
Experimental evidence does not substanti-
2 weeks and 10 months.
ate this route unless there has been some
trauma to the meninges. Difficult though
the direct route may seem, it has been Occurrence and distribution Meningococcal
shown that minute passages through the meningitis occurs in epidemics, especially
bone of the skull do occur and transmission in the Sahel part of Africa in a band stretch-
of organisms along this route is a possibility. ing from Senegal to Ethiopia. The epi-
Furthermore, if organisms are introduced demics are markedly seasonal occurring in
directly into the sub-arachnoid space, infec- the early part of the year when the tempera-
tion will only occur if a critical level is ture is hottest and relative humidity at its
exceeded (103 organisms in dogs), suggest- lowest. With the arrival of the rains, the epi-
ing that this route could frequently be in- demic abates (Fig. 13.4). The amount of rain-
vaded, but only when there is excessive fall (1100 mm) delineates the southern
infection does meningitis develop. An alter- boundary of the meningitis belt, whereas
100
80
60
40
20
0
Jan. Feb. Mar. Apr. May. June July Aug. Sept. Oct. Nov. Dec.
Month
No. meningitis Relative humidity %
Fig. 13.4. The seasonal variation of meningococcal meningitis in relation to relative humidity in the Sahel
region of Africa.
the northern boundary is the desert. Within lating a vaccination programme. Vaccine
this area, major epidemics, mainly of group can be used to immunize those most at risk
A, occur at 714-year intervals, with lesser concentrating on the 220-year age group
ones in between. and household contacts of cases. When
In addition to the meningitis epidemic there is an epidemic, mass vaccination
belt in Africa, there have also been epidem- should be given to communities in the
ics of group A organisms in India and Nepal, affected area, including vaccinating chil-
and group B in the Americas, Europe and dren below 2 years of age. It has been sug-
Pacific Island Nations. gested that an incidence of 15 cases per
Epidemic meningitis is commonest in 100,000 in a well-defined population for 2
the age group of 515 years, with males consecutive weeks heralds the beginning of
more frequently affected than females. an epidemic and the need to start mass vac-
Only about one in 500 persons infected cination.
with the organism will develop meningitis. A conjugated C vaccine has been found
Large, poor families and other conditions to be effective in all age groups, especially
where there is overcrowding, such as reli- young children, and in countries where
gious and social gatherings, refugee camps group C meningococcal disease is an import-
and labour lines, make meningitis more ant health problem it could be included
likely. in the national childhood vaccination pro-
gramme. If an epidemic is found to be
Control and prevention Overcrowding en- due to group C, then this vaccine should
courages the transfer of the infecting organ- be used.
ism and the carrier state, as well as
increasing the dose of bacteria that may be Treatment may need to be organized on
transmitted. All efforts should be made to a massive scale when an epidemic occurs
reduce overcrowding. It may be necessary by using dispensers, school teachers or
to close schools and reduce congregation of other educated people to care for isolated
people, such as in markets and religious communities. Temporary treatment centres
gatherings. In the long term, improvement (schools, churches, warehouses, etc.)
of housing and family planning will have may need to be set up, rather than bring
an effect. people into hospital. Benzyl penicillin or
Chemoprophylaxis should be given to chloramphenicol should be used, but in
close contacts, such as all family members, many countries, resistance to these antibiot-
school friends and anyone sharing in a large ics will require the use of cephalosporins.
communal sleeping place (such as a dormi- If the organism is unknown, use chloram-
tory). Rifampicin 10 mg/kg twice daily for 2 phenicol. In epidemics, long-acting chlor-
days, or if still sensitive to sulphonamides, amphenicol in oil preparations, given as
sulphadiazine 150 mg/kg for 2 days can be a single injection, avoids the problem
used. Chemoprophylaxis is not recom- of repeat injections. Dehydration is common
mended in large epidemics. and intravenous fluids may be required
There are several vaccines containing initially, followed by frequent drinks
either A and C, or A, C, Y and W135. administered by an attending adult.
Unfortunately, the very young and those
with acute malaria develop reduced Surveillance The regular epidemics that
immunity. There is also a genetic variation occur in Africa can be forecast and a
with some ethnic groups having a poor state of preparedness put into action. When
response. Due to these different factors, there is a case of meningitis, all contacts
duration of immunity varies from 3 years should be examined with nasalpharyngeal
or less in young children and must be swabs. Subtyping of the organism can assist
measured for each community when formu- in mapping out epidemics.
172 Chapter 13
13.7 Haemophilus influenzae countries H. influenzae infection occurs

(Meningitis and Pneumonia) before this age. Where vaccination pro-
grammes are starting or catch-up vaccin-
Organism Haemophilus influenzae, com- ation of adults and children over 18 months
monly serotype b (Hib). is to be done, a single dose of vaccine is
sufficient. Hib can safely be given at the
same time as meningococcal vaccine.
Clinical features Fever, vomiting, stiff neck
In the event of an outbreak of several
and rigid back in older children, bulging
cases of meningitis, vaccination should be
fontanelle in infants. A common cause of
given to all children under 5 years of age
secondary infection in measles and other
within the area. Contacts of all ages in
respiratory infections, resulting in pneumo-
households or close communities where
nia (see Section 13.2). H. influenzae can also
there are unvaccinated children should be
cause epiglottitis, cellulitis, septic arthritis,
given prophylaxis with rifampicin (see also
osteomyelitis, empyema and pericarditis.
Section 13.6).
Diagnosis The CSF is often purulent, but
this can occur in other causes of meningitis; Treatment is with ampicillin or chloram-
hence culture of CSF or blood should be phenicol.
made. Serological tests are also of value.
Surveillance All family and contacts of a
Transmission Airborne transmission of case of meningitis should be investigated
droplets and direct contact with nasal by nose swabs. Children under 5 years
pharyngeal secretions. The organism is of age, who have been in contact with a
carried asymptomatically in the nose of case, should be followed-up and treatment
carriers who are often the source of infection started if they develop early signs, such as
to infants. fever.

13.8 Pneumococcal Disease
Period of communicability Chronic nasal in-
fection can remain for a prolonged period. The pneumococcus causes a variety of dis-
eases, including ARI (Section 13.2), pneu-
monia (Table 13.1), meningitis (Table 13.2)
Occurrence and distribution H. influenzae is
and otitis media (Section 13.9), which are
the commonest cause of meningitis in
more conveniently covered under the vari-
infants and young children under 5 years
ous diseases they cause, but in view of the
of age, mainly 418 months of age. At pre-
availability of a vaccine, its possible use in
sent, it is a serious problem in developing
preventing these diseases will be discussed
countries, but with the advent of universal
here.
Hib vaccination, the incidence is likely to
decline considerably, as has been the case
in developed countries. Organism Streptococcus pneumoniae the
pneumococcus.
Control and prevention Routine vaccination
of all children with Hib vaccine is now Clinical features S. pneumoniae is the com-
recommended. Vaccine should be given at monest cause of ARI and pneumonia, pre-
the same time as DTP or as a combination senting with cough, fever and rusty
vaccine (DTP/Hib). National vaccination coloured sputum (from blood staining).
programmes may include a booster dose at Both bronchopneumonia and lobar pneumo-
1218 months, but in most developing nia result, leading to a high mortality in
Table 13.1. The causes of pneumonia.
Organism Clinical indicators Occurrence
Streptococcus pneumoniae Fever, cough, rusty sputum Infants, elderly

Haemophilus influenzae Slow onset, purulent sputum Secondary infection
Influenza A and B Fever, muscle pains Epidemic
Morbillivirus Measles Seasonal epidemics
RSV Wheezing, croup Seasonal winter peak
Adenoviruses Sore throat, conjunctivitis Children, winter months
Metapneumovirus Asthma, bronchiolitis Children
Coronavirus SARS Respiratory distress Close contact, animals?
Parainfluenza Croup, wheezing Children, immunodeficient
Mycoplasma pneumoniae Slow onset, malaise Epidemic, young adults
Chlamydia pneumoniae Slow onset, malaise Young adults
Staphylococcus aureus, Abscess formation Secondary infection, particularly of
Streptococcus pyogenes, influenza
Klebsiella pneumoniae
Legionella pneumophila Increasing fever, anorexia Air conditioners, males
Chlamydia psittaci Fever, unproductive cough Associated with birds
Coxiella burnetti Fever, weight loss Associated with sheep
Pneumocystis carinii Progressive dyspnoea Immunosuppressed, HIV
Cryptoccus neoformans Mycosis, disseminated Immunosuppressed, HIV
Nocardia asteroides Chronic, disseminated Immunosuppressed, HIV
Table 13.2. The causes of meningitis.
Organism Clinical indicators Occurrence
Neisseria meningitidis Fever, headache, rash Epidemic, African meningitis belt,

children and adults
Haemophilus influenzae Fever, vomiting, lethargy Infants
Streptococcus pneumoniae Fever, purulent CSF Infants, elderly
Mycobacterium tuberculosis Fever, cough, haemoptysis Children, young adults
Staphylococci Secondary infection Unsterilized instruments
Escherichia coli Floppy infant, not feeding Following delivery
Group B streptococci Floppy infant, not feeding Following delivery
Listeria monocytogenes Neonates, following birth Infection in the mother from
domestic animals or cheese
Campylobacter jejuni Diarrhoeal illness All ages (Section 9.2)
Echoviruses Clear CSF, rash Epidemic and seasonal
Coxsackieviruses Clear CSF, rash Epidemic and seasonal
Arboviruses Clear CSF, encephalitis Epidemic (Section 15.2)
Influenza A or B Reye syndrome Children given salicylates
Herpes zoster Reye syndrome Children given salicylates
Mumps virus Parotid swelling, encephalitis (Section 12.4)
Rubella virus Rash, encephalitis Neonates (Section 12.3)
Polio virus Flaccid paralysis Children (Section 8.10)
Herpes simplex type 1 and 2 Primary sore or genital infection Neonates, children or adults
Treponema pallidum Secondary or latent syphilis Adults (Section 14.4)
Cryptococcus neoformans Fungal infection Tropics, males
Leptospira interrogans Fever, myalgia, rash Infection from rat urine
Lymphocytic choriomeningitis Influenza-like symptoms Associated with mice
virus
Angiostrongylus cantonensis Nematode worm Eating snails and slugs
Borrelia burgdorfi Lyme disease Deer ticks (Section 16.8)
Negleria and Acanthamoeba Amoebic meningoencephalitis Swimming pools,
immunocompromised
174 Chapter 13
infants and the elderly. S. pneumoniae is Section 13.2 and in the same way as for
also the commonest cause of otitis media, otitis media in Section 13.9. Family plan-
causing fever and pain in the ear. If un- ning and the reduction of overcrowding
treated, this can lead to bacteremia and ful- should be advocated; smoking and having
minant meningitis, with a high fatality rate. open fires in the main living part of the
There is a high fever, lethargy and the patient house should be discouraged. Hand-wash-
rapidly descends into coma. S. pneumoniae ing and the careful disposal of discharges
is also a common cause of conjunctivitis. from nose, throat and the infected eye
should be practised.
Diagnosis is by culture of sputum, blood, A polysaccharide vaccine provides ap-
eye discharges or CSF. Gram stain of the proximately 65% efficacy in adults and can
characteristic blue staining diplococci probe used in high-risk patients, such as
vides a rapid indication of the likely healthy elderly adults living in institutions,
infecting organism. patients with chronic organ failure, those
with immunodeficiencies, splenectomized
Transmission is normally airborne spread of children and those with sickle cell disease.
droplets during sneezing or coughing from Unfortunately, the vaccine has limited effi-
infected persons or healthy carriers. Some cacy in children under 2 years of age and,
25% of persons carry S. pneumoniae in therefore, cannot be included in the routine
their nasopharynx, although these might childhood vaccination programme, and is
not all be the disease-producing serotypes. not currently used in developing countries
Transmission can also be by direct contact where a suitable vaccine would be of most
or through articles soiled with secretions, value. However, a conjugate vaccine was
such as handkerchiefs or clothes used to introduced into general use in USA in June
wipe the eye in conjunctivitis. 2000 for all children 23 months old and
younger, and for children 2459 months of
Incubation period 13 days. age who are at high risk of serious pneumo-
coccal disease. The vaccine has been shown
to be highly efficacious against invasive
Period of communicability is as long as secre-
pneumococcal disease, but only moderately
tions are produced in the clinical case, but
efficacious against pneumonia and otitis
the importance of healthy carriers is un-
media. At present, demand is outstripping
clear, with some possibly responsible for
supply, but depending on the results experi-
producing infection in the young or elderly
enced in USA and supply problems, it is
over considerable periods of time. Adequate
likely that this vaccine will soon be in-
treatment should render the case or carrier
cluded in routine childhood vaccination
non-infectious within 2 days.
programmes in other countries, including
the developing world. An alternative strat-
Occurrence and distribution Worldwide dis- egy may be to vaccinate pregnant women so
tribution, especially in developing coun- that maternal antibodies are passed on to the
tries, with ARI being a major cause of newborn child.
mortality in children. It is one of the com-
monest causes of terminal pneumonia in the
elderly in the developed world. Overcrowd- Treatment Penicillin G or erythromycin
ing and deprived socio-economic condi- are effective in the majority of cases, but
tions favour the disease. Miners and people where resistant strains are found or the
living in smoke-filled huts, such as in Papua child is seriously ill, cotrimoxazole, amoxi-
New Guinea, have an increased incidence. cillin or ampicillin should be used.
Control and prevention Active management Surveillance for ARI will be found in
and treatment of cases of ARI and pneumo- Section 13.2 and for otitis media in Section
nia should be carried out as outlined in 13.9.
13.9 Otitis Media Where the drum has ruptured, deafness

will result, leading to problems at school,
Acute ear infections are a common problem so what started off as a seemingly insignifi-
in children and are responsible for consider- cant problem can lead to poor development
able morbidity (Table 1.1). Acute middle ear and disability throughout the life of the in-
infection or otitis media is the main disease, dividual. Otitis media and deafness occur-
but this can lead to chronic otitis media or ring in the first 23 years of life can interfere
mastoiditis (chronic infection of the bony air with spoken language acquisition, leading
cells below the ear) or meningitis. to difficulties in communication, under-
The ear is joined to the nasopharynx standing and a barrier to education.
by the eustachian tube through which There is a particularly high level of
infecting organisms pass, so ear infections otitis media in Australian aboriginals and
are generally associated with respiratory the Inuit people of the Arctic with Pacific
infections. Islanders and native North Americans next
in order of magnitude. This may be due to
these people having larger eustachian tubes,
Organism S. pneumoniae and H. influenzae
which offer lower resistance to the passage
are the most common causative organisms,
of organisms.
but various viruses may initiate infection
and Pseudomonas aeruginosa and
Staphylococcus aureus are common in the Control and prevention Upper respiratory
discharges of chronic otitis media. infections should be adequately treated and
the eardrum always examined for redness
and bulging. The same risk factors that
Clinical features Fever and pain in the ear
cause ARI (Section 13.2) predispose to otitis
are the main presenting symptoms, but in
media, so relevant preventive action can be
the young child, crying and irritability will
instituted.
be more prominent. The eardrum is red and
The conjugate pneumococcal vaccine
bulges outwards, rapidly leading to perfor-
has been shown to be moderately efficacious
ation and the appearance of pus. There will
against otitis media and once it becomes
be deafness in the ear until the perforation
more universally available, it can be antici-
has healed, or permanent deafness if the
pated to contribute to a reduction of this
condition remains untreated.
infection.
The child with deafness should be
Diagnosis is on clinical grounds and the examined and if found to have a discharging
infecting organism can be cultured if the ear should be treated as below: if the ear-
eardrum has ruptured. drum does not heal, then corrective surgery
can be performed.
Transmission is secondary to an upper res-
piratory infection, such as a sore throat or
Treatment In acute otitis media, penicillin G
tonsillitis.
or erythromycin given systemically for 5
days may be sufficient, but if there is poor
Incubation period 14 days. response or perforation has occurred, then
cotrimoxazole twice a day or amoxicillin
Period of communicability Not normally three times a day for 5 days should be used.
transmitted from person to person, except In the chronically discharging ear, it is im-
as an upper respiratory infection. perative to dry the ear out with wicking,
which the mother can be taught to do.
Occurrence and distribution This is a very Clean tissue paper is twisted into a point
common condition throughout the world and placed in the ear, replacing it as soon
and many children develop ear infections as it becomes wet and repeating until the ear
during the course of their childhood. remains dry. The child should not swim or
176 Chapter 13
water allowed to enter the ear when wash- lower (<1%) following endemic or sporadic
ing. Boric acid in spirit ear drops can be streptococcal infections. Healthy primary
instilled to help in drying the ear. school children are commonly found to be
carriers of GAbHS. Cutaneous streptococcal
Surveillance Surveys of deaf and partially infection is a frequent precursor of acute
deaf children will give an indication of the nephritis, but has not been shown to cause
amount of otitis media leading to perfor- ARF. Scarlet fever, however, is associated
ation of the eardrum. Where finances with ARF.
permit, this is best done by typanometry, Why only a small percentage of the
but a simple test using the spoken voice youthful population develop ARF remains
can give a rough estimate: a mystery. ARF patients, as a group, show a
higher antibody level to group A streptococ-
. responds to a whisper no deafness; cal antigens suggesting that repeated expos-
. responds only to the normal voice mod- ure to GAbHS may precipitate illness.
erate hearing impairment; Susceptibility is due to the immunological
. responds only to a loud voice severe status of the host, including both humoral
deafness. and cell-mediated immunity, with a 2%
familial incidence of ARF. A larger propor-
tion of children born to rheumatic parents
13.10 Acute Rheumatic Fever contract the disease. The carditis of RHD
might be the result of an autoimmune mech-
anism developing between group A strepto-
Organism Group A b-haemolytic strepto-
coccal somatic components and myocardial
coccus (GAbHS). The M-protein in the wall
and valvular components.
of the streptococcus is responsible for its
virulence and certain predominant sero-
Incubation period of the initial streptococ-
types, 1, 3, 5, 6, 14, 18, 19, 24, 27 and 29,
cal infection is 13 days and 19 days for
have a much greater rheumatogenic poten-
ARF.
tial.
Period of communicability 1021 days of an
Clinical features ARF is a delayed non-sup- acute, untreated streptococcal infection.
purative sequel of upper respiratory tract
infection or scarlet fever with GAbHS. ARF Occurrence and distribution ARF/RHD is the
is important because it can lead to rheumatic commonest form of heart disease in children
heart disease (RHD), the resulting cardiac and young adults in most tropical and
damage producing considerable morbidity developing countries. The peak incidence
and mortality. is 515 years, but both primary and recur-
rent cases can occur in adults. There is
Diagnosis of ARF is based on major and neither a sex predilection nor a racial predis-
minor clinical criteria and a rising serum position.
antibody titre of a recent streptococcal infec- ARF is a disease of lower socio-
tion by the antistreptolysin-O titre (ASOT), economic groups, particularly those massed
antihyaluronidase or anti-DNase B tests. in the densely populated areas of urban met-
ropolitan centres. It is widespread with a
Transmission ARF results from an inter- high incidence in South Asia, Pacific
action of the bacterial agent, human host Islands, North and South Africa and urban
and environment. GAbHS are transmitted Latin America. It has been estimated that
from person to person through relatively RHD causes 2540% of all cardiovascular
large droplets, up to a distance of 3 m. ARF diseases in the developing world.
develops at a fairly constant rate of 3%
following untreated epidemics of strepto- Control and prevention There is no per-
coccal pharyngitis. The attack rate is much manent cure for RHD and the cumulative
expense of repeated hospitalization for sup- diazine may be used for oral prophylaxis.
portive medical care is a considerable drain Regular taking of prophylaxis is essential
on the meagre health resources of develop- and compliance is a major problem. Patients
ing countries. The only reasonable solution with no evidence of cardiac involvement
is the prevention of rheumatic fever. ARF is should receive prophylaxis for a minimum
now a rare condition in developed countries of 5 years after the last attack of ARF, while
due to improved housing, reduction of over- those with carditis should continue until
crowding and the provision of adequate they are 25 years old. Prophylaxis should
health services, so this should be the long- be continued with penicillin in the pregnant
term aim. woman.
Prevention of the first attack (primary The emphasis of a prevention pro-
prevention) is by proper identification and gramme should be on health education,
antibiotic treatment of streptococcal infec- early diagnosis and treatment of sore throats
tions. The individual, who has suffered an and the provision of treatment facilities at
attack of ARF, is inordinately susceptible to primary level.
recurrences following subsequent strepto-
coccal infection and needs protection
(secondary prevention). While primary pre- Surveillance In developing strategies,
vention is preferable, the incidence of ARF baseline data on streptococcal epidemiology
as a sequel of streptococcal sore throat is and ARF/RHD prevalence in high-risk
never greater than 3%, even in epidemics. groups should be collected. A fully estab-
A vast number of infections would need to lished programme centre would operate a
be treated in order to achieve any meaning- central register, coordinate case-finding
ful reduction of the total number of sore surveys, run a system of secondary prophy-
throats and streptococci are responsible for laxis (especially follow-up) and promote
only 1020% of them. health education. Community control of
Most cases of severe RHD would be pre- ARF and RHD is viable only if it is firmly
vented by adequate prevention of recur- based on existing health services, which are
rences of ARF. No matter how mild the first an integral part of the primary health care
attack of ARF, secondary prevention with activities in the country. It is especially rele-
intramuscular long-acting benzathine peni- vant to school health services, by screening
cillin G 1.2 million units should be given at children and supporting those on secondary
monthly intervals. Penicillin V or sulpha- prophylaxis.
14
Diseases Transmitted Via Body Fluids
This category includes infections transmit- rounded papules, scattered all over the
ted from one human to another by the physio- body. These lesions exude serum, which is
logical fluids of the body: blood, serum, highly infectious. There is also a mild peri-
saliva, seminal fluid, etc. Transmission is ostitis in focal bony sites, but these and the
normally direct, but indirect transmission skin lesions normally heal with little
via fomites or flies can occur in some cases. residual damage. It is the tertiary stage that
It includes the treponematoses, both the appears after an asymptomatic period and
sexually and non-sexually transmitted. some 5 years after initial infection that
Sexual transmission accounts for the largest results in gross damage to skin and bone,
number of persons affected by these leading to hideous deformities. The oppos-
diseases. ite ends of the body are affected with
These are the diseases of close personal destructive lesions of the nasal bones
contact, either thriving in conditions of poor (gangoza) and scarring, and deformity of
hygiene, or in the most intimate contact of the lower limbs (sabre tibia).
all by sexual intercourse. They are, there-
fore, social diseases, determined by the Diagnosis is by finding T. p. pertenue in the
habits and attitude of people and it is only exudates of lesions. In the motile state, the
by effecting change in these values that any spirochete can be seen by dark ground mi-
permanent improvement will occur. croscopy or stained by Giemsa or silver salts.
The serological tests for syphilis (Section
14.1 Yaws 14.4) are positive.
Organism Treponema pallidum subspecies Transmission Yaws is a disease of poor hy-

pertenue. giene, with close bodily contact being the
manner in which infection is commonly
Clinical features Yaws is a non-venereal transmitted. Flies may be involved in trans-
treponemal disease affecting both the skin mission from clothing and dressings that
and bone. It commences as a primary papule have become contaminated by fluid from
that starts to heal, but after a period, varying sores. The spirochete cannot penetrate un-
from a few weeks to several months, it is broken skin, but requires a minor skin abra-
followed by generalized lesions, multiple sion or cut by which to enter.
178
Disease Transmitted Via Body Fluids 179
Incubation period 28 weeks. areas, but unfortunately, there is now a

resurgence. Newly trained health personnel
Period of communicability can be as long as are unaware of the disease and penicillin
moist lesions persist in the untreated case, has been replaced by other antibiotics in
which can be several years. the treatment of common infections.
In the long term, improvements in the
level of hygiene and socio-economic status
Occurrence and distribution Yaws is pre- will reduce the conditions in which yaws
dominantly an infection of children, with thrives.
the mother becoming infected if she did not
acquire her infection in childhood. The
large overcrowded family with a poor stand- Treatment is a single injection of benzathine
ard of hygiene is the characteristic environ- penicillin G (1.2 million units for an adult,
ment in which yaws so readily spreads. The 0.6 million units for a child). Response is
need to stay indoors and keep close together very satisfactory and lesions heal within
for warmth in the rainy season might be the 23 weeks.
reason why the disease is more common at
this time of year. Surveillance Due to the possible appearance
Yaws is restricted to the moist tropical of new cases, a continuing awareness of
areas of the world in a band that passes the disease needs to be kept, with the
through the Caribbean, South America, taking of smears from any suspicious
Africa, Southeast Asia and the Pacific lesions. It is likely that search will discover
Islands (Fig. 14.1). A resurgence of cases more cases, so treat cases and contacts
has occurred in West Africa, India, South- along the same lines as in the eradication
east Asia, Pacific Islands, South America campaigns.
and the Caribbean.
Control and prevention Yaws with its rapid 14.2 Pinta

response to a single injection of penicillin
has been the subject of successful mass Organism Treponema carateum.
treatment campaigns in the endemic parts
of the world. Treatment in a mass campaign Clinical features The disease has many simi-
is to: larities to yaws, commencing as a primary,
painless papule. Secondary lesions, which
. all those with clinical signs of yaws; develop in 312 months, are flat and erythe-
. household, school and other close con- matous, but cover large areas of the body.
tacts; Tertiary lesions result in pigmentary
. any person suspected of incubating the changes often with large patches of leuco-
disease. derma. Only the skin is involved in pinta
with lesions commonly on the face and
The campaign is preceded by health educa- extremities.
tion encouraging all people to come forward
with any suspicious lesions. Each village is
visited in turn, everyone examined and Diagnosis is made on clinical grounds with
treatment given to cases, contacts or sus- supporting evidence from positive sero-
pects. A follow-up surveillance service logical tests for syphilis. T. carateum can
treats missed cases or new infections. This be found in the serous exudates from lesions
can readily be done by an effective rural by dark ground microscopy.
health service.
The success of the WHO mass cam- Transmission Direct contact or carriage by
paigns against yaws resulted in the virtual flies has been suggested as the means of
disappearance of the disease from many transmission. Trauma, especially to the
180
Chapter 14
Fig. 14.1. Distribution of the endemic treponematoses. (Reproduced by permission from Weekly Epidemiological Record, World Health Organization, Geneva.)
lower limbs, might facilitate entry of shared drinking vessels and eating utensils
organisms. is considered the most likely route. Direct
contact with lesions is also a likely method
Incubation period 13 weeks. of spread. It resembles venereal syphilis in
many of its features except that it is not
spread venereally.
Period of communicability is probably sev-
eral years, while secondary lesions are pre-
sent. Incubation period 2 weeks to 3 months.
Occurrence and distribution Pinta is re- Period of communicability is for as long as

stricted to moist tropical areas of Central moist lesions are present, generally several
and South America (Fig. 14.1), occurring in months.
communities with poor hygiene, such as in
the Amazon and Orinoco basins. Adults and Occurrence and distribution The non-
adolescents are mostly involved. Recent venereal form of syphilis is found in local-
surveys found the disease to be naturally ized foci in Africa and the Arabian
dying out. peninsula (Fig. 14.1), where it is known
locally as Bejel or Njovera. Predominantly
Control and prevention Mass treatment with an infection of childhood, it thrives in con-
penicillin in the same manner as for yaws ditions of poverty, overcrowding and where
(see above). there is limited sanitation.
Control and prevention It is a disease of low

14.3 Endemic Syphilis personal hygiene where crowding together
and contact with lesions readily occurs.
Cross-immunity is shared with venereal
Organism Treponema pallidum subspecies
syphilis, therefore, eradication of the dis-
endemicum, which is indistinguishable
ease by mass treatment generally means a
from the T. pallidum that causes venereal
replacement by the more serious and devas-
syphilis.
tating venereal syphilis. Family planning,
better housing, education and improving
Clinical features The primary lesion is com- the general standard of hygiene might be
monly found at the angle of the mouth, a preferable control strategy in such situ-
appearing as a raised mucous plaque. ations.
A more florid skin infection follows with
moist papules under the arms and between
the buttocks and a maculo-papular rash on Treatment is with penicillin in the same
the trunk and limbs, resembling venereal manner as yaws.
syphilis. Destructive tertiary signs in the
skin, nasopharynx and bones develop after
months or years, but the nervous and cardio- 14.4 Venereal Syphilis
vascular systems are rarely involved.
Organism Treponema pallidum subspecies
Diagnosis is made on clinical grounds in en- pallidum.
demic areas and by detecting the organism
with dark ground microscopy. Serological Clinical features. The primary lesion of
tests for syphilis are positive and remain so syphilis is the chancre (a painless ulcer
for many years. with a serous discharge) normally found on
the genitalia of males and females, but can
Transmission Because of the site of the pri- occur in the mouth, on the breast or in the
mary lesion on the mouth, transmission by ano-rectal region. A regional lymph node
182 Chapter 14
often enlarges to form a bubo. The primary Because of the almost identical nature
lesion heals spontaneously after a few of the T. pallidum of endemic syphilis and
weeks, but 6 weeks to 6 months later, venereal syphilis, it has been considered
the signs of secondary syphilis appear. that venereal syphilis developed from this
This may take several forms, but the more benign form. Once a venereal method
commonest is a maculo-papular rash and of transmission had been developed, the dis-
mucocutaneous condylomata around the ease was able to extend its boundaries from
genitalia and anus. As the infection is sys- the tropics to the Arctic.
temic, a generalized lymphadenopathy and Infection with T. p. endemicum confers
splenomegaly can occur, often accompanied immunity to venereal syphilis and infection
by fever. Following the period of secondary with T. p. pallidum gives immunity to the
syphilis, there is a latent phase after which other treponem infections and from con-
the destructive cardiovascular (aortic aneur- tracting venereal syphilis again, but this is
ysm) and central nervous symptoms (men- reduced by HIV infection. There is also some
ingitis, paresis or tabes dorsalis) occur, often innate resistance or inadequacy of the trans-
many years later. Should a woman be preg- mission mechanism as only some 30% of
nant while she has syphilis, her fetus may be contacts of a known infected source become
seriously affected. If she is pregnant during infected.
early syphilis, then the child is likely to be
stillborn, while the later stages of the disease Incubation period 990 days (usually 3
are more likely to produce a live-born child weeks).
suffering from congenital defects (deafness,
sabre tibia, Hutchinson teeth and CNS
involvement). Period of communicability Up to 1 year after
the primary lesion first appears.
Diagnosis is confirmed by finding T. p. pal-
lidum in the serous exudate from a chancre Occurrence and distribution The venereal
or by gland puncture. This can be examined diseases are totally cosmopolitan, taking
by dark ground microscopy or immuno- no account of climate, ethnic group or social
fluorescent staining. Serological tests can class; wherever sexual contact occurs,
assist in the diagnosis or be used in epidemi- venereal diseases can occur also. It is
ological studies. The rapid plasma reagin estimated that there are some 12 million
(RPR) is a sensitive test, while specific cases in the world today, with a large pro-
tests, such as the fluorescent treponemal portion of these in the tropics. The highest
antibody absorbed (FTA-Abs) test or incidence is amongst the 2024-year
T. pallidum haemagglutination antibody age group, followed by those 2529 years
(TPHA), are more difficult and expensive old.
to perform. Cross-reaction between the Syphilis is predominantly a disease of
Treponema of yaws, pinta and endemic urban areas and in conditions of sexual
syphilis negate the differential diagnosis of imbalance, such as mines, military estab-
these diseases. All patients with syphilis lishments and amongst seamen. With the
should be encouraged to have an HIV rapid urbanization that has occurred in the
test because of the high frequency of dual developing world and large movements of
infection. migrant labour, syphilis has been on the in-
crease in the tropics. When the migrant
Transmission Syphilis is transmitted by workers return to their homes and families,
direct contact with an infectious lesion or they bring venereal disease back with them.
its discharge during sexual intercourse. The main reservoir of infection is generally
Transmission can also occur congenitally in commercial sex workers or deserted
or from blood transfusion if the donor is in women forced into prostitution to support
the early stages of syphilis. Kissing can more their children. Due to the prolonged incuba-
rarely transmit the spirochete. tion period, the hidden site of the primary
lesion within the vagina, and the latent Treatment is with benzathine penicillin 2.4
period of the disease, syphilis is either not million units as a single dose (but often
suspected or purposely hidden. A large given intramuscularly at two different
number of contacting males can be infected sites). Alternatively, tetracycline 500 mg
by a single female. four times a day or doxycycline 100 mg
twice daily, both for 14 days can be given,
Control and prevention Contact tracing and especially in the patient allergic to penicil-
the adequate treatment of all cases is the lin and not pregnant.
main method of control, but in developing
countries, it is largely an impossible task. In Surveillance Antenatal and family planning
restricted communities, such as mines or clinics provide an important opportunity to
plantations, it can be used to considerable examine a large number of women and also
value, but in the vast, sprawling urban prevent cases of congenital syphilis. Rou-
slums where people come and go and ad- tine RPRs should be performed and all posi-
dress is not known, it is a hopeless task. tive cases fully investigated and treated.
The prohibition of commercial sex workers
only drives the practice underground and
is generally not acceptable in developing 14.5 Gonorrhoea
countries where they form a recognized seg-
ment of society in many cultures. A prefer- Organism Gonorrhoea is a bacterial disease
able answer is to try and examine known caused by Neisseria gonorrhoeae (the gono-
commercial sex workers at regular intervals coccus).
and encourage them to bring in others for
check-ups. A commercial sex worker aware Clinical features In the male, infection com-
of the damage that can be caused by the mences as a mucoid urethral secretion,
disease, once converted, can be a greater which soon changes to a profuse, purulent
proponent of health education than any discharge (as opposed to NGU where it is
trained worker. scanty, white, mucoid or serous). The dis-
Health education should start at school, charge is best seen first thing in the morning
encouraging delay of first sexual experience (dew drop) and a smear should be made
and the benefits of a monogamous relation- from this before the patient urinates. The
ship. Programmes should also be targeted at main symptom is pain on micturition, but
high-risk groups, such as miners, truck the degree of discomfort is very variable. In
drivers and the commercial sex industry, the female, the infection generally passes
encouraging safe sex and the use of unnoticed, but may present with urethritis
condoms. The likelihood of contracting a or acute salpingitis. It is this latter presenta-
sexually transmitted infection (STI) is pro- tion of the disease that can lead, in an acute
portional to the number of sexual partners. or chronic form of pelvic inflammatory dis-
Diagnostic and treatment facilities need ease, to sterility in the female. This is a ser-
to be widely available on a walk-in basis. It ious problem in the unmarried woman and a
is preferable to provide special clinics as cause of divorce in the married. In the male,
well as the routine health services. Unfortu- untreated or improperly treated infection
nately, many private practitioners, often not can result in urethral stricture, while gener-
even medically qualified, offer inadequate alized symptoms of arthritis, dermatitis or
treatment, so encouraging resistant organ- meningitis can rarely occur in either sex. In
isms to develop as syphilis is often con- the pregnant woman, there is a danger of the
tracted at the same time as other STIs. newborn infant developing gonococcal con-
All pregnant women should be tested junctivitis at the time of delivery. The dis-
for syphilis, preferably both in early and covery of this infection in the newborn
late pregnancy. All blood donors should be infant may be the manner in which the
screened (see also Box 14.1). infection is found in the woman.
184 Chapter 14
Box 14.1 The control of sexually transmitted infections (STIs).
There has been a considerable increase in STI with new STIs appearing or their relative importance
changing. Some of the reasons for these changes are:
. increasing world population, especially of younger age groups;

. urbanization and migrant labour;
. increasing travel and mixing of populations;
. alteration of social values and increasing promiscuity;
. development of contraceptive practice;
. ignorance of STI and lack of sex education;
. vulnerability of women biologically, culturally and socio-economically;
. inadequate treatment and development of resistant organisms.
International travel has allowed a mixing of cultural groups that would otherwise have remained isolated,
potentiating the spread of different types and strains of STI. The development of resistant strains has posed a
problem of imported cases to the developed world, but has left the developing world with an intolerable
situation that they are economically unable to deal with.
STIs are more prevalent in young people, yet with an increasing world population, it is predominantly
these younger age groups that are expanding at a more rapid rate than others. This increase in the youth of
the world has thrown a greater strain on the education services so that health education, especially of STIs, is
neglected.
Change has occurred in the social structure whereby traditional values and the monogamous married
couple are no longer regarded as the norm. The development of contraceptives has freed the woman from
the risk of unwanted pregnancy, but at the same time, increased the opportunity for developing an STI.
Married women are particularly vulnerable when they are abandoned or their husbands have to find work
away from the confines of the family. STIs are often asymptomatic in women so they do not seek treatment,
putting their lives and those of any future children at greater risk.
Generally, the risk of developing an STI is more recognized, rather than the shock that previously led to
concealment or recourse to treatment from a medical quack. Also contraceptive practice should not be
discouraged for it is the problem of the rapidly expanding young population that is a major contributory
factor. The key is health education with a combined approach of contraceptive advice and STI information.
If this is to succeed there must be a considerable increase in treatment facilities, especially in urban areas.
Standard treatment regimes should be decided by specialists and administered by primary healthcare
workers. Improved treatment facilities, contact tracing, training of health workers and more effective
drugs will not only reduce the prevalence and seriousness of STIs, but also of HIV infection.
Diagnosis Due to the similarity in presenta- ate. N. gonorrhoeae is unable to penetrate

tion of gonococcal and non-gonocococcal stratified epithelium, but has a predilection
urithritis, the emphasis is on making a diag- for mucous membranes where it produces
nosis syndromically of a urethral discharge. an accumulation of polymorphonuclear
A smear should be made and stained with leucocytes and outpouring of serum to give
Gram stain, the finding of Gram-negative the characteristic discharge.
intracellular diplococci indicating gonococ- Important factors in the transmission of
cal infection. Where facilities permit, the gonorrhoea are:
discharge should be cultured, but as the or-
ganism is very sensitive, it must be inocu- . the short incubation period;
lated on to a culture plate or placed in . the often asymptomatic disease in women
transport medium (less satisfactory) as (estimated to be 80%);
soon as possible. . promiscuous sexual intercourse;
. urbanization and changing social values;
Transmission is by sexual intercourse . use of contraceptives;
or with contact of the infected mucous exud- . inadequate treatment.
The combination of a short incubation as a person presents at a clinic. Health edu-

period and promiscuous sexual activity cation concentrating on the dangers of STIs
means that a large number of people can is the main preventive action (see also under
become infected in rapid succession. Since syphilis above and Box 14.1). The eyes of
women are often largely unaware of their babies as they are being born should be
infection they serve as a continuous reser- wiped and a 1% aqueous solution of silver
voir of the disease. Urbanization changes nitrate instilled (Section 7.7).
the social balance that occurs in the village,
traditional values and taboos are lost Treatment which used to be a simple matter
and promiscuity develops. Contraceptives with penicillin, is now fraught with prob-
allow increased opportunity for sexual lems of resistance not only to this antibiotic,
intercourse although the condom provides but to many others that have subsequently
limited protection. The contraceptive pill by been tried. Any recommended treatment
reducing the acidity of genital secretions regime may be ineffective in certain parts of
removes some of the natural defences, the world and local expertise must be con-
while the intra-uterine contraceptive device sulted to develop routines that are compat-
encourages mechanical spread of infection ible with the resistance patterns and
to the uterus and tubes. Improper treatment available resources. Recommended regi-
both by doctors and quacks, usually with mens are:
grossly inadequate doses of antibiotics, has
led to chronic infections and the develop- . ciprofloxacin 500 mg as a single oral dose
ment of resistant organisms. (but not in pregnant women or children), or
. azithromycin 2 g orally as a single dose, or
Incubation period 27 days (average 3 days). . ceftriaxone 125 mg by single intramuscu-
lar injection, or
Period of communicability can be months in . cefixine 400 mg as a single oral dose, or
untreated cases, especially hidden infec- . spectinomycin 2 g by single intramuscular
tions in women. injection.
Occurrence and distribution The number of Patients diagnosed with gonorrhoea often
cases of gonorrhoea in the world today is have Chlamydia infection as well, so treat-
estimated to be some 62 million. Under- ment for this condition should be combined
reporting, illegal treatment and the protec- as a routine (see below).
tion of contacts make any standard methods
of case treatment and contact tracing quite Surveillance Strains of the gonococcus re-
inadequate in most developing countries. sistant to the standard treatment regime in
Gonorrhoea is not so much found as a reser- the country are likely to be imported from
voir in commercial sex workers as more time to time, so sensitivity should be regu-
widely distributed amongst the promiscu- larly tested and the treatment regime modi-
ous under-25-year-olds. fied accordingly.
Control and prevention Where possible,

cases presenting at STI clinics should 14.6 Non-gonococcal Urethritis (NGU)
be encouraged to bring their partners (or
provide information so that they can Organism A number of organisms have been
be traced) for counselling and treatment. found to be responsible for urethritis not
Alternatively, contact cards can be sent caused by the gonococcus, including
anonymously to all contacts of a case, rec- Chlamydia trachomatis, Ureaplasma urea-
ommending them to present at a clinic. lyticum, Trichomonas vaginalis and Myco-
Condoms can be given out at the same time plasma hominis.
186 Chapter 14
Clinical features A low-grade urethritis with avoided until both partners are free of
mucoid rather than purulent discharge in signs. While cases of gonorrhoea should
the male, in which intracellular diplococci always be treated for NGU, if gonorrhoea
are not found in the smear, suggests NGU. has been excluded, then cases of NGU do
Infection is a low-grade discharge in the not also need to be treated for gonorrhoea.
female or is often asymptomatic so that a If a low-grade offensive discharge with some
reservoir of infection can occur if simultan- staining persists in the female, or irritation
eous treatment to both sexual partners is not in the male, this is probably Trichomonas
given. Sterility in women can result if the infection, which is effectively treated with
infection is not treated. In areas where gono- metronidazole 2 g orally or tinidazole 2 g
coccal urethritis is common, the prevalence orally in a single dose.
of NGU is also high so treatment should be
given for both conditions. Surveillance Several STIs can occur to-
gether, hence NGU is an indicator of pos-
Diagnosis This differs markedly in differ- sible syphilis and gonorrhoea, which
ent parts of the world with developing should always be looked for.
countries adopting a syndromic approach
(see above under gonorrhoea), while de-
veloped countries specifically test for 14.7 Lymphogranuloma Venereum
Chlamydia. Where possible, diagnosis
should be made by smear and culture, the
Organism Chlamydia trachomatis.
absence of intracellular diplococci indicat-
ing NGU. The nucleic acid amplification
test (NAAT) or IF test with monoclonal anti- Clinical features Lymphogranuloma vener-
body can be used on urethral or cervical eum is a chronic infection presenting as a
swabs. small painless papule, vesicle or ulcer on
the genitalia that often goes unnoticed, lym-
phadenitis being the clinical sign. The
Transmission is by sexual intercourse.
lymph nodes become grossly enlarged and
C. trachomatis and T. vaginalis are risk
generally suppurate with fistulas and fibro-
factors for HIV infection in the female.
sis developing, especially in the rectal area if
treatment is delayed.
Incubation period 12 weeks.
Diagnosis is by finding the organism in
Period of communicability In the asymptom-
lymph node aspirate with immunofluores-
atic case, infection can continue for a con-
cence or DNA probe.
siderable period of time.
Transmission Although sexual intercourse is

Occurrence and distribution NGU is more
considered the main means of transmission,
common than gonorrhoea and is found all
infection can also happen by direct contact
over the world with high levels in the sexu-
with open lesions.
ally promiscuous.
Control and prevention is the same as for Incubation period 330 days.
gonorrhoea and syphilis (see above).
Period of communicability is for as long as
Treatment is with azithromycin 1 g orally in there are active lesions, which may be for
a single dose, doxycycline 100 mg orally several years.
twice daily for 7 days, erythromycin
500 mg orally four times a day for 7 days or Occurrence and distribution Although it
tetracycline 500 mg orally four times daily occurs worldwide, lymphogranuloma
for 7 days. Sexual intercourse must be venereum is commoner in the tropics, espe-
cially in sub-Saharan Africa and parts of Occurrence and distribution Mainly in

Asia. the tropical regions of the world, especially
in southern India and Irian Jaya/Papua New
Control and prevention Treatment should be Guinea and amongst the aboriginal people of
commenced as soon as the diagnosis has Australia. It is less commonly found in
been made, the patient being advised to Africa and people of African origin, such as
refrain from sexual intercourse and close in the Caribbean and the northern part of
contact with others until all lesions have South America. It is a disease of the sexually
healed. Other methods of control are the active 2040-year age group, in males more
same as for syphilis and gonorrhoea above. than females, but children under 5 years also
contract the disease (presumably from con-
Treatment is with doxycycline 100 mg daily tact with their parents).
for 14 days, erythromycin 500 mg four times
daily for 14 days or tetracycline 500 mg four Control and prevention Control is the same
times daily for 14 days. as for syphilis and gonorrhoea above. Care
should be taken to prevent transmission
from open lesions to others and other parts
of the body.
14.8 Granuloma Inguinale
Treatment is with azithromycin 1 g orally on
Organism Calymmatobacterium granulo- the first day followed by 500 mg daily for a
matis. maximum of 14 days, doxycycline 100 mg
twice daily for 14 days, erythromycin
Clinical features Granuloma inguinale is a 500 mg orally four times a day for 14 days
chronic, progressive, ulcerating disease of or tetracycline 500 mg four times daily for
the ano-genital area without regional lym- 14 days.
phadonopathy. An initial lesion on the geni-
talia becomes eroded and ulcerated with Surveillance As with all STIs, it is possible
new nodules forming at the margins as the that more than one STI is present.
lesion extends. The lesions readily bleed on
contact and ulceration can continue to pro-
duce extensive destruction. Carcinoma of 14.9 Chancroid
the vulva has been reported to be associated
with granuloma inguinale. Organism Haemophilus ducreyi.
Diagnosis is made from smears or scrapings Clinical features An acute venereal infection
of the lesions stained with Giemsa, in which characterized by a soft chancre on the exter-
intracellular rod-shaped organisms (Dona- nal genitalia and regional lymphadenop-
van bodies) are found. athy. The lesion has an indurated base of
the chancre, which differentiates it from
Transmission The disease is transmitted syphilis. Chancroid is a predisposing cause
by direct contact with lesions either via of HIV infection with which it is frequently
sexual intercourse or other methods. It is associated.
frequently associated with anal intercourse.
Diagnosis The organism can be identified
Incubation period 116 weeks. with Gram-stain from the exudate of lesions,
but this is often difficult due to secondary
Period of communicability is while open infection.
lesions are present, which can be for a con-
siderable period of time in the untreated Transmission is by sexual intercourse or
patient. direct contact with lesions.
188 Chapter 14
Incubation period 314 days. Incubation period 212 days.
Period of communicability is as long as Period of communicability 27 weeks during

lesions continue to discharge, which can be the initial clinical infection and 5 days
months in the untreated case. during a recurrence.
Occurrence and distribution Predominantly Occurrence and distribution A worldwide

found in the tropical regions of the world and increasing problem amongst the
where it is common in men who probably sexually active. As the infection is difficult
obtain their infection from a commercial sex to treat there is a recurrent reservoir of infec-
worker. tion with each clinical attack and if one of
these should occur during delivery, then
Control and prevention See syphilis neonatal death or disability will result.
above.
Control and prevention The same as with
Treatment Chancroid can be treated with gonorrhoea and syphilis (see above).
one of the following regimes: Infected persons should be warned of the
increased risk of developing HIV infection.
. azithromycin 1 g orally as a single dose, or
. ceftriaxone 250 mg intramuscularly as a Treatment There is no cure, but acyclovir
single dose, or 200 mg orally five times daily for 7 days or
. ciprofloxacin 500 mg orally twice daily for acyclovir 400 mg orally three times a day
3 days, or for 7 days, or other analogues will reduce
. erythromycin 500 mg orally four times the formation of new lesions, pain and the
daily for 7 days. period of healing, but not recurrent attacks.
14.10 Genital Herpes

14.11 Human Papilloma Virus (HPV)
Organism Herpesvirus simplex type 2
Organism Human papilloma virus (HPV).
(HSV2); less commonly type 1 (HSV1).
Clinical features Painful vesicles develop on Clinical features The main clinical presen-
the genitalia or surrounding area, which can tation is genital warts on the external geni-
subsequently ulcerate. Healing occurs after talia or within the vagina, but a large
initial infection only to recur at frequent proportion of infected persons show no clin-
intervals, often precipitated by stress or ical signs. When cellular immunity is de-
menstruation. Infection of the neonate can pressed condylomata acuminata, large
occur during delivery resulting in encephal- fleshy growths in moist areas of the peri-
itis, liver damage or lesions in the eye, mouth neum develop. However, the most serious
or skin. Infection with HSV2 carries an consequence of HPV infection is the devel-
increased risk of developing HIV infection. opment of carcinoma, particularly of the
cervix, but the anus and penis can also be
Diagnosis is made on clinical presenta- involved.
tion and by scrapings of the lesions where
characteristic multi-nucleated giant cells Diagnosis Cervical smears stained by
with intranuclear bodies are seen on micro- the Papanicolau method can detect pre-
scopy. cancerous changes.
Transmission is by sexual intercourse or Transmission is by sexual intercourse,

direct contact, such as oralgenital, or to but direct contact, as with other warts, is
the infant during delivery. possible.
Incubation period 23 months. 14.12 Human Immunodeficiency Virus

(HIV)
Period of communicability Probably for
a considerable period of time as cancer Organism Human immunodeficiency virus
of the cervix appears to be associated with (HIV) either type 1 (HIV-1) or type 2 (HIV-
the cumulative number of sexual encoun- 2), HIV-1 being more pathogenic.
ters.
Occurrence and distribution It has been esti- Clinical features HIV infection leads to a dis-
mated that between 9% and 13% of the ruption of the helper T4 cell-mediated
world population is infected with HPV, immune mechanisms, resulting in an
which is some 630 million people. Seventy increased susceptibility to opportunistic
percent of these infections are sub-clinical infections. This breakdown of the bodys de-
with only a proportion developing genital fence system and the range of symptoms pro-
warts and some 2840 million the pre- duced is called acquired immunodeficiency
malignant condition. The prevalence of syndrome (AIDS). Presentation is generally
chronic persistent infection is about 15% by the symptoms of the opportunistic infec-
in developing countries and 7% in tion, so can be many and varied.
developed. Eighty per cent of the worldwide Initially, there may be an acute retro-
incidence of cervical cancer is in developing viral infection with fever, sweating and my-
countries. algia, but after this subsides, there is a
dormant period for months or years, after
Control and prevention The usual methods which symptoms of an opportunistic infec-
of reducing STI, such as delaying the age of tion occur. The opportunistic infections are:
first intercourse, monogamous relationship
and the use of condoms will all assist in . oral, vulvovaginal candidiasis, or of the
decreasing the likelihood of developing oesophagus, trachea, bronchi or lung;
HPV infection. The promotion of cervical . pulmonary or extrapulmonary tubercu-
smear testing in developed countries has losis (Section 13.1);
allowed detection of pre- and early cervical . atypical disseminated mycobacteriosis;
cancer amenable to surgical treatment, but . severe bacterial infections, such as pneu-
few if any developing countries are able to monia (Table 13.1) or pyomyocitis;
afford such a service. . Pneumocystis carinii pneumonia (Table
Three HPV vaccines are currently under 13.1);
trial and offer considerable hope that either . non-typhoid Salmonella septicaemia;
the non-infected can be protected or that a . oral hairy leucoplakia;
therapeutic vaccine can be used in the . reactivated varicella (Section 12.1);
already infected. . cytomegalovirus of an organ other than
liver, spleen or lymph nodes;
Treatment of the warts is by cryotherapy, . herpes simplex, visceral or not resolving
podophyllin or with trichloroacetic acid, mucocutaneous;
but HPV infection will remain. . disseminated mycosis, such as histoplas-
mosis, coccidioidomycosis or penicilium;
Surveillance Cytological services for . cryptococcosis, extrapulmonary;
screening women at regular intervals have . cryptosporidiosis with diarrhoea (Section
been shown to be cost-effective in reducing 8.2);
cervical cancer and should be set up wher- . isosporiasis or microsporidiosis with
ever resources permit. diarrhoea;
190 Chapter 14
. toxoplasmosis of the brain (Section 17.5); . oropharyngeal candidiasis;

. intractable scabies not responding to . chronic progressive or disseminated
treatment (Section 7.1); herpes simplex infection;
. disseminated Strongyloides (Section . generalized lymphadenopathy;
10.4);
The presence of either generalized Kaposi
. florid Chagas disease with acute myocar-
sarcoma or cryptococcal meningitis is
ditis or meningoencephalitis (Section sufficient for the diagnosis of AIDS.
15.11); If a test for HIV antibody in an adult or
. reactivated leishmaniasis (Section 15.12); adolescent (>12 years old) is positive then
. lymphoma (Section 1.1); the person is considered to have AIDS if
. Kaposis sarcoma (Section 1.1); one or more of the following conditions are
. HIV encephalopathy; present:
. progressive multifocal leucoencephalopa- . >10% body weight loss or cachexia, with
thy. diarrhoea or fever, or both, intermittent or
constant, for at least 1 month, not known to
Any process that stresses the immune be due to a condition unrelated to HIV
mechanism, such as repeat infections, will infection;
accelerate progression to AIDS. Tubercu- . cryptococcal meningitis;
losis and leprosy are affected by the disrup- . pulmonary or extra pulmonary
tion of the immune process. Any person tuberculosis;
with tuberculosis who contracts HIV . Kaposi sarcoma;
infection will progress more rapidly, while . neurological impairment that is sufficient
to prevent independent daily activities,
tuberculoid leprosy cases can convert to
not known to be due to a condition
lepromatous.
unrelated to HIV infection;
. candidiasis of the oesophagus;
Diagnosis and AIDS case definition With . clinically diagnosed life-threatening or
such a range of possible symptoms and recurrent episodes of pneumonia, with or
lack of resources in developing countries to without aetiological confirmation;
perform serological confirmation, various . invasive cervical cancer.
attempts have been made to formulate a
case definition for AIDS. The one most Where full diagnostic facilities are available,
widely followed is the 1985 Bangui defin- the Centres for Disease Control and Preven-
ition, updated in 1994 by WHO, which is as tion (CDC) definition of infection (2000) can
follows: be used:
In adults or adolescents ($18 months), a
An adult or adolescent (>12 years of age) reportable case of HIV infection must meet
is considered to have AIDS if at least two one of the following criteria:
of the following major signs are present in
combination with at least one of the minor 1. Positive result on a screening test for HIV
signs listed below, if these signs are not
antibody (e.g. repeatedly reactive enzyme
known to be due to a condition unrelated to
HIV infection. immunoassay), followed by a positive result
on a confirmatory test for HIV antibody
Major signs (e.g. Western blot or immunofluorescence
. weight loss $ 10% of body weight; antibody test)
. chronic diarrhoea for more than
1 month; or
. prolonged fever for more than 1 month
(intermittent or constant);
2. Positive result of a detectable quantity on
Minor signs any of the following HIV virologic tests:
. persistent cough for more than 1 month;
. generalized pruritis dermatitis; . HIV nucleic acid detection (e.g. DNA
. history of herpes zoster; polymerase chain reaction);
. HIV p24 antigen test, including neutral- infants blood at the time of delivery. HIV
ization assay; is found in breast milk with about a 25%
. HIV isolation (viral culture). chance of it being transmitted to the infant.
Serological tests may not become posi-
Transmission is by: tive for up to 3 months after the person
became infected, so it is possible for a person
. sexual contact with an infected person; to transmit infection before they are shown
. inoculation with infected blood or blood to be positive.
products (including unsterile needles and
syringes); Incubation period to full-blown AIDS ranges
. from an infected mother to child before, from 1 to 18 years with a mean of 10 years. In
during delivery or for up to 2 years after if perinatal infection, the incubation period is
breast-fed; often shorter than 12 months. With such a
. from tissue transplants (rare). long incubation period the epidemic will
last for about 100 years if an effective inter-
Sexual contact is the commonest method of vention is not found.
transmission, with both heterosexual and
homosexual practice. The important epi-
demiological factor is number of sexual con- Period of communicability Infectiousness is
tacts so that prostitutes or promiscuous highest during initial infection, probably
homosexuals with hundreds, if not thou- extending throughout the life of the individ-
sands of new contacts annually are at ual, increasing again as immunity becomes
greatest risk. However, one contact with an suppressed. With the extension of life of the
infected person is able to produce infection. treated individual the period of communic-
Anal intercourse carries a higher risk of ability is also increased, although virus
infection than vaginal. There is no evidence shedding is diminished.
of increased risk during menstruation
and circumcision is protective in the Occurrence and distribution HIV infection
male. There is an association with other has now spread to most parts of the world,
STIs, particularly genital herpes simplex but is particularly prevalent in Africa, the
virus type 2 and ulcerating conditions, Americas, Europe (including Russia),
such as chancroid. Other STIs may potenti- South and Southeast Asia and an increasing
ate infection. problem in China. Some 25 million people
Blood transfusion of infected blood will have so far died from AIDS and 40 million
almost always transmit HIV. Pooled blood, are infected, comprising 36.8 million adults,
such as for producing factor VIII for the treat- 18.3 million of which are women, and 3.1
ment of haemophilia, is particularly danger- million children under 15 years of age (at
ous because it contains donations from 2003). Sixty-four per cent of all cases of
many people, any of which could be AIDS are in Africa with southern Africa
infected. Syringes and needles, if they are being the worst affected part of the contin-
not properly cleaned and sterilized, can con- ent. Nearly 40% of women of age 1524
tain small quantities of blood sufficient to years attending ante-natal clinic in Swazi-
transmit infection. This method may be re- land were HIV-positive, with only slightly
sponsible for many infections in developing lower rates for Botswana and Zimbabwe.
countries and is an important way of trans- In contrast though there has been a reduc-
mitting infection amongst drug abusers. tion in prevalence in East Africa where the
Transmission by needle stick injury can epidemic first started.
occur, but is uncommon. Initial spread in East Africa was along
The infected mother can pass on infec- transport routes, where lorry drivers made
tion to her child. Infection can be transmit- use of local bar-girls at each of their stops. In
ted congenitally, but it is more likely to South Africa, HIV infection was introduced
occur from a mixing of the mothers and into the mining communities in which it
192 Chapter 14
spread rapidly via prostitutes. Sadly many developed, other control measures are
infections in developing countries have required.
been due to the use of poorly sterilized To prevent sexual spread:
needles when people have attended at
clinics for other illnesses. . limit the number of sexual partners,
Parts of South America and some Carib- encouraging monogamous relationships;
bean islands have very high incidence rates . avoid sexual contact with persons at high
due to the general attitude towards promis- risk, such as commercial sex workers,
cuity. Prostitution and injecting drug use are bisexuals and homosexuals;
responsible for very high rates in parts of . encourage male and female condom
Thailand and India, from which spread is use;
being encouraged through illegal networks. . provide adequate facilities for the detec-
Girls from Yunnan in China sent to work in tion and treatment of STIs;
brothels in Thailand returned infected with . provide counselling and HIV testing;
HIV and disseminated it to other parts of . provide general education for girls and
the country. However, both Thailand and sex education to both boys and girls;
Cambodia have now shown sustained re- . provide lifestyle training (how to say
ductions in the past 45 years. no).
A worrying trend has been the un-
changed incidence in Western countries, To prevent blood spread:
with an increasing rate in Europe, despite
the availability of antiretroviral (ARV) ther- . screen all blood for transfusions;
apy. Indeed this suggests that treatment, by . test donors before they give blood;
prolonging the life of HIV-infected persons, . only use blood transfusions when essen-
is increasing transmission, or the availabil- tial;
ity of treatment is reducing the fear of infec- . discontinue paid blood donors;
tion and allowing more risky behaviour. It is . use disposable syringes, needles, giving
hoped that ARV therapy will reduce the sets, lancets, etc. or ensure they are prop-
stigma of AIDS and allow preventive pro- erly sterilized;
grammes to work in developing countries, . injecting drug users should be discour-
so both strategies must proceed at the same aged from sharing equipment, preferably
time. using needle exchange schemes;
HIV-1 is common in the Americas, . medical workers should wear gloves when
Europe, Asia, Central and East Africa, dealing with possible infected blood (e.g.
whereas HIV-2 is found in West Africa or at delivery and in the laboratory).
in people that acquired their infection there.
To prevent perinatal spread:
Control and prevention Methods of control . advise infected mothers about the pos-
and prevention are aimed at the three routes sible risk to their infant and themselves if
of transmission sexual, blood and peri- they become pregnant;
natal. Several vaccines are under trial in- . good obstetric practice, especially redu-
cluding a prime boost technique using a cing trauma in procedures, such as artifi-
DNA vaccine followed by HIV in a modified cial rupture of membranes and fetal scalp
vaccinia virus, but the problem with all the monitoring, and only cutting the cord
vaccine candidates so far developed is the when it has stopped pulsating;
rapid rate at which the HIV virus alters its . priority ARV therapy should be given to
antigenic makeup. A live, attenuated vac- HIV-positive pregnant women and to the
cine has been developed, which seems to newborn infant (nevirapine has been
be effective, but because of the ability of shown to be effective in Uganda, but
the retrovirus to alter itself so rapidly, it is zidovudine and lamivudine can also be
likely to be too dangerous. Until a vaccine is used);
. provide information on breast-feeding to made to rectify the situation. Individual

allow each mother to decide. treatment is a highly specialized subject,
but will probably consist of two nucleoside
Caesarean section should not be encouraged analogues, a non-nucleoside reverse
in developing countries as the risk to the transcriptase inhibitor and/or a protease in-
mother in subsequent pregnancies is consid- hibitor, a three- or four-drug regime being
erably increased, but might be the strategy found to be more effective than a two-drug
of choice in developed countries. WHO regime. A second-line regimen should be
recommends that no change should be available in case of toxicity or treatment fail-
made in vaccination programme to mothers ure. Any opportunistic infection must re-
and children even though they may be ceive specific treatment for the condition.
infected with HIV, except in the child
with clinical AIDS who should not be Surveillance The prevalence of HIV
given BCG. infection can be estimated by testing an-
HIV is not spread by: onymously blood that has been obtained
. mosquitoes; for other purposes, such as in ante-natal or
. casual contact such as shaking hands, or STI clinics. Population-based surveys have
lavatory seats; been conducted in Zambia, South Africa
. through food, water or the respiratory and some other countries. Numbers of
route. cases of AIDS are reported to WHO using
the case definitions outlined above.
CONTROL PROGRAMMES The main method of
control is health promotion and should
involve community leaders, religious organ- 14.13 Hepatitis B (HBV)
izations and NGOs. This can be to the gen-
eral public to supply them with the correct Organism Hepatitis B virus (HBV).
information or to specific groups. The most
cost-effective health education will be to Clinical features In many parts of the
high-risk groups, such as commercial sex developing world, HBV infection is common,
workers, homosexuals, single workers, etc. but only about 30% show any symptoms.
However, they are difficult to motivate and However, these symptomatic cases present
it is probably better to concentrate effort on as a more severe disease than hepatitis A,
school children. Girls should have equal with a persistent jaundice, often resulting in
opportunity for education, whereas sex edu- liver damage.
cation should be an integral part of the After an insidious onset with anorexia,
school curriculum. Counselling and testing nausea and abdominal discomfort, jaundice
facilities need to be readily available as well then develops, from which the patient either
as programmes on mother-to-child transmis- recovers or goes on to develop chronic active
sion. Improved diagnosis and treatment fa- disease. Low-grade infection continues
cilities for STIs need to be made available, with periods of jaundice alternating with
providing early and adequate treatment. remissions, but invariably cirrhosis de-
Condoms can be dispensed at clinics, velops. The disease is more serious in
markets or at any suitable social marketing those over 40 years of age, in pregnant
opportunity (see Box 14.1). women and newborn infants. Hepatocellu-
All persons with HIV infection, includ- lar carcinoma is associated with chronic
ing those under treatment, are at risk of pass- hepatitis B infection.
ing on infection to others and should be
counselled about preventive measures to be Diagnosis can be made by finding the sur-
taken. face antigens (HBs Ag). There are four sub-
types adw, ayw, adr and ayr, which vary in
Treatment is largely unavailable in most de- their geographical distribution providing
veloping countries, but efforts are being useful epidemiological markers. A further
194 Chapter 14
antigen e (HBe Ag) is a marker of increased Control and prevention Hepatitis B vaccine
infectivity as well as indicating active viral can be given to those at risk and as part of the
replication in hepatocytes (which may EPI programme. If given before infection, it
result in liver damage). prevents the development of disease and the
carrier state. Ideally, Hepatitis B vaccine is
Transmission can occur from blood, serum, given at the same time as DTP, but in coun-
saliva and seminal fluid. It is a hazard of tries where perinatal transmission is
blood transfusions, renal dialysis, injections common, such as in Southeast Asia, a dose
and tattooing. It can be transmitted by sexual at birth is recommended. Immunity is
intercourse and during delivery. The virus thought to last for at least 15 years in the
has been found in some blood-sucking fully vaccinated. There is convincing evi-
insects (e.g. bed bugs), but transmission by dence that reduction of carriers can prevent
this means has not been shown to occur. the development of primary liver cell
Certain people are more infectious cancer.
than others resulting in a carrier state, with Preventive methods are strict aseptic
the period of communicability being consid- precautions in giving blood transfusions, in-
erable. The risk of an infant becoming jections and the handling of blood. All blood
infected from a carrier mother can be donors should be screened with contribu-
5070% in some ethnic groups. There is tions to pooled blood being particularly
a greater likelihood of the mother passing scrutinized. The control of STIs has been
on the infection if she has acute hepatitis covered above. Homosexual practice is par-
B in the second or third trimester or up to ticularly liable to lead to HBV infection. Per-
2 months after delivery. A high titre of sur- sons at risk should be vaccinated.
face e antigen or a history of transmission to
previous children increases the risk of a Treatment There is no specific treatment,
mother infecting her infant. The carrier but alpha-interferon and lamivudine have a
state is more common in males and in limited effect in some people, particularly in
those that acquired their infection in child- the early stage of infection. Long-term treat-
hood. ment may also be of value.
Incubation period 6 weeks to 6 months (usu- Surveillance As with HIV infection, blood
ally 912 weeks), a larger inoculum of virus obtained in antenatal clinics, STI clinics or
probably resulting in a shorter incubation for other purposes can be anonymously
period. tested for HbsAg. Surveys in developing
countries demonstrated the high levels of
carriers, so with the implementation of rou-
Period of communicability From several
tine vaccination, follow-up surveys will
weeks before the onset of symptoms, con-
monitor the effectiveness of the vaccination
tinuing until the end of clinical disease,
programmes.
unless the person becomes a carrier in
which case it is life long.
Occurrence and distribution The carrier state 14.14 Hepatitis C (HCV)

has been estimated to be present in over 350
million people with varying rates in differ- Organism Hepatitis C virus (HCV).
ent parts of the world: Western Europe, 1%;
South and Central America 27%; and Clinical features Similar in many respects to
Africa, Asia and Western Pacific, >8%. In- hepatitis B, HCV produces a milder disease,
fection is thought to occur commonly in in- but as many as 1020% will progress
fancy or early childhood in the more to cirrhosis and 1% to liver cancer in later
endemic areas. life.
Diagnosis is difficult, dependent upon normally a self-limiting infection with only

detecting antibodies to HCV and confirming about 5% continuing into the chronic
by a recombinant immunoblot assay (RIBA). form of HDV. However, with super-
PCR is now commonly used. infection (HDV infection of an already
HBV-infected person), there is a severe
Transmission is due to the use of poorly ster- acute hepatitis with 80% continuing to
ilized needles, giving-sets and other chronic active hepatitis, often progressing
methods of parental administration and so to cirrhosis. Hepatocellular carcinoma
is common in developing countries and in due to HDV occurs with about the same
those who abuse drugs in developed coun- frequency as with HBV. The mortality
tries. Sexual or perinatal transmission due to HDV is between 2% and 20% making
probably only occurs rarely. it some ten times greater than for HBV
alone.
Incubation period 2 weeks to 6 months (usu-
ally 69 weeks). Diagnosis is made by detecting antibody to
HDV using a serological assay.
Period of communicability Weeks before the
start of clinical symptoms to lifelong. Transmission is the same as for HBV with the
main route of transmission via infected
Occurrence and distribution Infection is blood and blood products. Super-infection
found worldwide in the general population produces the greatest amount of virus and
in developing countries and mainly in chance of HDV transmission.
drug users sharing equipment in developed
countries. However, there are probably Incubation period 28 weeks.
many more cases than present figures sug-
gest and WHO estimates that there are 200 Period of communicability It is probably
million people infected, which amounts to most infectious in the weeks prior to symp-
3% of the worlds population. This means toms, becoming negligible once disease is
that there are about 170 million chronic car- manifest.
riers who could go on to develop cirrhosis or
liver cancer. Occurrence and distribution Areas of high
prevalence are the Mediterranean, South-
Control and prevention There is no vaccine west and Central Asia, West Africa and
for HCV, so all precautions need to be taken certain Pacific Islands. In the Amazon
to prevent further spread by rigorous adher- Basin, there is a particularly fulminant
ence to sterilization of needles and instru- genotype (III), which carries a high mortality
ments. rate. In Western Europe and North America,
infection is endemic in the drug addict
Treatment and surveillance See hepatitis B community. Worldwide WHO estimates
above. that more than 10 million people are
infected.
14.15 Hepatitis Delta (HDV) Control and prevention Since HDV is de-
pendent on HBV infection, the main strategy
Organism Hepatitis delta virus (HDV) is de- of control is to reduce HBV by vaccination.
pendent on HBV infection of the person. However, once chronically infected with
Either both viruses can infect at the same HBV, vaccination offers no protection. This
time or HDV infects an already infected makes all the other methods for the control
HBV carrier. of HBV relevant.
Clinical features With coinfection (both vir- Treatment and surveillance See hepatitis B
uses infecting at the same time), there is above.
196 Chapter 14
14.16 Ebola Haemorrhagic Fever virus has been found in monkeys in the
Philippines exported for experimental pur-
Organism Virus of the Filoviridae group of poses. The focal nature suggests a zoonosis,
organisms. but despite extensive search, no reservoir
has been found. Bats have been infected ex-
Clinical features Illness presents with perimentally, but do not die, so might be
sudden onset of fever, headache, muscle responsible for maintaining the virus in the
pains, sore throat and profound weakness. wild.
This progresses to vomiting, diarrhoea and
signs of internal and external bleeding, gen- Control and prevention The strictest level of
erally with the occurrence of liver and barrier nursing is required taking particular
kidney damage. Mortality is 5090%. care to avoid contact with blood and all se-
cretions. Patients who die must be buried or
Diagnosis is by ELISA for specific IgG and cremated immediately using the same pre-
IgM antibody or by PCR, but should only be cautions, with relatives being forbidden to
carried out in laboratories with maximum take the body away for burial. Patients who
facilities for protecting staff. recover must be counselled about the
dangers of sexual intercourse and the infect-
Transmission is by person-to-person contact ive nature of semen.
via blood, secretions, semen or tissues All contacts of a case and accidental
of an infected person. Infected blood, espe- contacts by healthcare workers must be
cially via syringes, causes the most serious quarantined and the temperature checked
infections, while transmission has occurred twice a day. Surveillance should continue
via semen up to 7 weeks after clinical for 3 weeks from the date of contact.
recovery.
Infection has also occurred through Treatment There is no specific therapy and
handling ill or dead chimpanzees, but it is hyper-immune serum does not offer any
thought that like humans, they are suscep- long-term protection.
tible to the infection rather than being a
reservoir. Surveillance Outbreaks should be reported
to WHO, neighbouring countries and those
Incubation period 221 days. with air connections so that surveillance can
be mounted on travellers.
Period of communicability From start of
symptoms and for up to 10 weeks for
seminal fluid. Healthcare workers are par- 14.17 Marburg Haemorrhagic Fever
ticularly liable to become infected, espe-
cially during the phase of vomiting and A closely related virus infection, first iden-
diarrhoea. Contact with blood is invariably tified from laboratory monkeys in Marburg,
fatal. Germany, produces a similar illness to Ebola
haemorrhagic fever, but with a mortality of
Occurrence and distribution The main focus about 25%. Cases have occurred in Uganda,
of infection is the rain forest of Central Kenya, Zimbabwe and Congo (Zaire). In all
Africa, outbreaks having occurred in other respects, it is similar to Ebola haemor-
Sudan, Congo (formerly Zaire), Gabon and rhagic fever to which reference should be
Uganda. Another focus of an Ebola-related made above.
14.18 Lassa and CrimeaCongo and Marburg disease and are highly infec-
Haemorrhagic Fevers tious through blood, urine and other body
fluids, but as they are both primarily zoon-
Lassa and CrimeaCongo haemorrhagic oses, they are covered in Sections 17.9 and
fevers have similar presentations to Ebola 16.9.2, respectively.
15
Insect-borne Diseases
By adopting a more specific means of trans- and the next chapter on ectoparasites, which
mission, some parasitic organisms have attach to the host, such as fleas and lice.
become dependent on vectors for carriage Since the vector is all-important in transmis-
to a new host. Several vectors may be used sion, the diseases transmitted by them are
by some infecting organisms, such as arbo- grouped according to the vector.
viruses, but often a parasite is restricted to
only one kind of vector. This may appear to
reduce the chance of infection, but com- 15.1 Mosquito-borne Diseases
pared with the haphazard method of scatter-
ing large numbers of organisms into the The mosquito is the most important vector
environment, in the hope that one of them of disease, because it is abundant, lives in
will find a new victim, using a vector can close proximity to humans and needs to feed
have a greater chance of success. The para- on blood (the female must have a blood meal
site is carried right to the new host and in for the development of its eggs). Incredibly it
many cases introduced directly into it. is a very delicate insect, being easily blown
Often, a development stage takes place in by the wind, is a weak and slow flier, and
the vector and the infective stage continues susceptible to climatic change. Its success
for the rest of the vectors life. However, lies in its opportunism and rapid develop-
transmission depends on the vector being mental cycle, allowing large numbers to be
able to find a new host, often within a produced in a short period of time. Once a
limited period of time, at a vulnerable stage suitable breeding place appears, be it a few
in the life cycle, where control methods are puddles after a rainstorm or a man-made
most likely to succeed. water storage tank, mosquitoes will quickly
Vector transmission is one of the com- lay their eggs. These develop within a short
monest methods of spreading disease and period of time into a large number of adults.
many of the infections transmitted this way Each may become a vector, and although
are of major importance, so large sections many will die, there will be a sufficient
need to be devoted to them. Such is the number left to seek out suitable blood
importance that vector-transmitted diseases meals and transmit infection.
are discussed in two chapters this chapter, Some parasites are specific to certain
which includes all the vectors that use types of mosquitoes (e.g. malaria and
flight, such as mosquitoes and tsetse flies, the anophelines), while others, like the
198
Insect-borne Diseases 199
arboviruses, are less selective and utilize 15.2 Arboviruses

many different species. Different kinds of
mosquitoes may be required in a complex Arthropod-borne virus (arbovirus) infec-
transmission cycle such as yellow fever. tions occur in an epidemic form in different
Development of the parasite within parts of the world. Many viruses have been
the mosquito may be morphological without identified (see Table 15.1 and Chapter 19)
multiplication (as with filaria), asexual and are grouped into three-symptom
(arbovirus) or sexual reproduction (malaria). complexes.
Each of these methods confer advantages
and disadvantages, such as the sheer
number of organisms produced by asexual
(a) Those producing mainly fever and/or
reproduction, or the opportunity to produce
arthritis
strains of varying type with sexual repro-
duction, but if the mosquito does not
live long enough for these developmental 15.2.1 Chikungunya, Onyong-nyong, West
stages to take place, then all is lost. Nile, Orungo, Oropouche and Ross River
There are two main groups of mosqui-
toes the anophelines and the culicines This group of infections are summarized
(which includes Aedes), separated by in Table 15.1. They present as a dengue-
characteristics found in all of the develop- like disease (see below) with headache,
ment stages (Fig. 15.1). The adult Anopheles fever, malaise, arthralgia or myalgia, lasting
mosquito raises its hind legs away from for a week or less. Rashes are common
the surface, easily remembered by its stance in Chikungunya, Onyong-nyong and West
being like one side of a letter A, while Nile. Chikungunya may present as a haem-
the lava lies horizontal to the surface. The orrhagic fever in India and Southeast
eggs are laid singly and have little floats Asia (see below), and West Nile and Oro-
on each side. In contrast, culicine mosqui- pouche as encephalitides. Ross River pre-
toes rest horizontal to the surface, their dominantly presents as a polyarthritis
larvae hang down from a single siphon and rash. There are many other arbovirus
and their eggs have no floats and are often infections presenting as fever, listed in
laid in rafts. It is better to try and differen- Chapter 19.
tiate an adult male, with bushy antennae,
from a female before subsequently separat- Diagnosis of all the arbovirus infections is
ing anophelines from culicines by the generally made on clinical grounds, once
length of the palps. More precise species the initial cases have been identified by
identification is required to identify which virus isolation in a specialist laboratory.
mosquitoes are principal vectors, but this A rise in specific IgM in serum or CSF is
needs entomological help. useful, if available.
Mosquitoes differ in their habits, some
preferring to take blood meals on humans Incubation period 215 days.
(anthropophilic) or on animals (zoophilic)
or are non-specific depending on which is Period of communicability of all the arbo-
most readily available. They also have par- virus infections is as long as there are still
ticular biting times, either only indoors, infected mosquitoes remaining.
only outdoors or a mixture of the two. The Susceptibility is general, but infection
biting period can be mainly during the night leads to immunity, probably life-long. In
or predominantly in the daytime. All these endemic areas, they are diseases of children,
different parameters need to be measured in otherwise they are epidemic, affecting all
determining the importance of each type of age groups and both sexes. In 2002, there
mosquito as a vector. were epidemics of West Nile virus in Israel,
200 Chapter 15
Fig. 15.1. The main differences between anopheline and culicine mosquitoes.
Canada and the USA (resulting in 3231 cases (b) Those presenting as fever and
and 176 deaths in the USA), countries where encephalitis
this infection had not occurred before.
While most people suffered minor illness, 15.2.2 Western equine, Eastern equine, St
individuals with weakened immune Louis, Venezuelan, Japanese, Murray Valley
systems, such as people with chronic dis- and Rocio
eases, those on chemotherapy or the elderly
suffered more serious effects, including This group of diseases present with a high
meningitis and encephalitis. fever of acute onset, headache, meningeal
Table 15.1. The important arbovirus infections of humans.
Virus Distribution Vectors Reservoir
Mainly fever or arthritis

Chikungunya Africa, South and Southeast Aedes aegypti, Ae. Baboons, bats,
Asia africanus, Ae. rodents, monkeys
leuteocephalus
Onyong-nyong E. Africa, Senegal Anopheles gambiae, A. Mosquito?
funestus
West Nile Africa, Asia, Europe, USA Culex pipens molestus, C. Birds?
modestus, C. univittatus
Oropuche Trinidad, South America Mosquitoes, possibly Monkeys, sloths, birds
Culicoides
Orungo W. Africa, Uganda Ae. dentatus, Anopheles
spp.
Ross River Australia, New Zealand, C. annulirostris, Ae. vigilax, Mosquito
Pacific Islands Ae. polynesiensis
Fever and encephalitis
Western Equine Americas C. tarsalis, Culista melanura Birds

Eastern Equine Americas, Caribbean C. melanura, Aedes and Birds, rodents
Coquillettidia spp.
St Louis Americas, Caribbean C. tarsalis, C. nigripalpus, C. Birds
quinquefasciatus
Venezuelan Central/South C. tarsalis and other Culex, Rodents
Equine America, Caribbean, parts of Aedes, Mansonia,
USA Sabethes, Psorophora,
Anopheles, Haemagogus
Japanese East, South and Southeast C. tritaeniorhynchus, C. Birds, pigs
Asia gelidus, C. fuscocephala
Murray Valley New Guinea, Australia C. annulirostris Birds
Rocio Brazil Probably mosquitoes Birds? Rodents
Haemorrhagic fevers
Yellow fever South America and Africa Ae. aegypti, Ae. africanus, Monkeys, mosquitoes
Ae. simpsoni, Ae. furcifer/
taylori, Ae. luteocephalus,
Haemagogus spp.
Dengue 1, 2, 3 Asia, Pacific, Caribbean, Ae. aegypti, Ae. albopictus, Human/mosquito,
and 4 Africa, Americas Ae. scutellaris group, Ae. (Monkeys in jungle
niveus, Ochlerotatus cycle)
Rift Valley Africa, Southwest Asia Ae. caballus, C. theileri, C. Sheep, cattle, etc.
quinquefasciatus and Mosquito
other Culex and Aedes
Kyasanur forest South India Haemaphysalis (hard ticks) Rodents, monkeys
CrimeanCongo Europe, Africa, Asia Hyalomma spp. (hard ticks) Domestic animals
haemorrhagic
fever
202 Chapter 15
irritation, stupor, disorientation, coma, Some arbovirus infections can also be

spasticity and tremors. Fatality rates are spread by non-mosquito arthropods, such
variable with up to 30% in Japanese, Eastern as KFD and CrimeaCongo fever (see
equine and Murray Valley. Their distribu- Section 16.9.2).
tion, vectors and reservoirs are summarized
in Table 15.1. Japanese encephalitis is Control and prevention of arbovirus
covered in more detail below. infections The main method of control is
From the reservoir bird or animal, the the destruction of vector mosquitoes and
organism is often first transmitted to another breeding places. The most important are
host, such as horses in the equine arbovirus Culex and Aedes mosquitoes, which live in
infections. Humans are then mainly infected collections of water close to the home.
from mosquitoes feeding on the horses. Search is made for larvae and all breeding
places destroyed. A simple method is to use
Incubation period is 515 days. Susceptibil- school children, making it a game or giving a
ity is highest in the very young and old, with reward for the number of breeding places
inapparent infection occurring at other age found. Water tanks, blocked drains, dis-
groups. carded tin cans or old tyres are favourite
breeding places. Large breeding areas (such
as water tanks) can be covered, screened,
treated with insecticides or natural preda-
(c) Haemorrhagic fevers tors introduced (e.g. fish or dragonfly
larvae). An improvement on covering water
15.2.3 Yellow fever, dengue, Rift Valley, pots and containers is to use an insecticide-
Kyasanur forest disease, CrimeanCongo and treated pot cover rather than place the
Chikungunya insecticide in the container.
Where there is an epidemic in a com-
Apart from yellow fever, which will be pact area such as a town, the quickest and
covered in more detail below, a group of simplest (although expensive) method of
generally mild viral fevers including bringing the epidemic to an end is to use
dengue, Rift Valley, Kyasanur forest disease fogging or ULV aerial spraying. Compared
(KFD) and Chikungunya, which at certain with working hours lost, this can be a cost-
places and occasions take on a severe form effective procedure.
resulting in vascular permeability, hypovo- Personal prevention with repellents
laemia and abnormal blood clotting. Infec- (see malaria) can protect the individual.
tion commences as an acute fever, malaise, The infected case should be nursed under a
headache, nausea or vomiting with petechial mosquito net so as not to infect other mos-
rashes, severe bruising, epistaxis and bleed- quitoes. A vaccine is available for Vene-
ing from various sites. After a few days, zuelan, Eastern and Western equine
sudden circulatory failure and shock may encephalitis, which can be used both for
occur producing a mortality of up to 40%. humans and horses.
Rift Valley Fever is normally a disease Where an animal reservoir is involved,
of cattle, sheep, camels and goats, in which some restriction of animals or reduction of
high mortality can cause considerable eco- rodents can help. In Rift Valley fever, special
nomic loss, but spread to humans also precautions should be taken in handling
occurs. A large number of unexplained abor- domestic animals and their products by
tions in livestock is often the first sign of an wearing gloves and protective clothing.
impending epidemic. The disease was nor- Blood and other body fluids of patients are
mally restricted to Africa, but in 2000, it also infectious, so barrier nursing should be
spread to Saudi Arabia and Yemen, raising instituted. All animals should be vaccin-
the fear that it could infect other parts of ated. A vaccine for use in humans is under
Asia and Europe. trial.
Treatment There is no specific treatment, in urban areas, where suitable stagnant

supportive therapy being given (Ribavirin water permits the breeding of vector
may be of value). mosquitoes.
Surveillance Regular checks should be made Incubation period 414 days.

on mosquito-breeding places and control
methods instituted where mosquitoes are Period of communicability As long as there
found. People can be taught to regularly are infected mosquitoes continuing to bite
search their home areas for mosquito breed- people. Mosquitoes can also become
ing. (See further under yellow fever below.) infected by feeding on a clinical case any
time during the illness.
15.3 Japanese Encephalitis (JE) Occurrence and distribution Serological

surveys indicate that most people living in
Organism The Japanese encephalitis virus endemic areas contract sub-clinical infec-
(JEV) is a member of the flavivirus family, tion before the age of 15 years. However,
the same group of viruses as West Nile and young children and adults, who have not
St Louis encephalitis. been infected as children (including visit-
ors), may get clinical disease and possibly
Clinical features Japanese encephalitis pre- severe disease, with 2030% mortality.
sents as a sudden onset of fever, headache, There are about 50,000 cases and 10,000
body aches and pains. Mild cases recover deaths reported annually.
completely, but a high proportion develop The endemic area is South and South-
encephalitis and progressive coma. Chil- east Asia, particularly Cambodia, Laos,
dren under 10 years of age may present Vietnam, Thailand, Malaysia, Myanmar,
with gastro-intestinal symptoms and con- Indonesia, Philippines, the Indian sub-
vulsions, rapidly leading to death. Those continent, Russia and a decreasing inci-
who survive the severe disease may have dence in China, Japan and Korea. A small
residual neurological or psychiatric disabil- outbreak in Torres Strait islands is a worry-
ities. ing sign that the infection might spread into
northern Australia. Risk within any of these
Diagnosis is by finding the specific IgM in countries is greatest during the rice-growing
CSF or serum. The virus can be cultured in season and when an epidemic is ongoing.
specialist laboratories.
Control and prevention Agricultural
Transmission The main vectors are Culex tri- methods, such as drying out rice fields
taeniorhynchus, C. gelidus and C. fuscoce- when no crop is growing or decreasing the
phala, mosquitoes that predominantly number of crops, can reduce the period of
breed in rice fields. The reservoir of infec- risk. Personal protection with long sleeved
tion is probably wading birds, but domestic clothing, the wearing of trousers and use of
pigs also harbour the virus, from which it is repellents can reduce mosquito biting. The
transferred to humans. The mosquito breeds mosquito bites during the daytime, so babies
when the rice fields are flooded and the first and young children should be made to sleep
green shoots appear, dying off when the rice under insecticide-treated mosquito nets.
grows and shades the water, thereby dis- The main method of prevention is the use
playing a marked seasonality, with a peak of vaccination to all children in endemic
period of July and August in Thailand, areas, after the age of 1 year, so as not to
August in China, and September and No- interfere with remaining maternal anti-
vember in India and Nepal. In irrigated bodies. However, allergic reactions to the
areas, mosquito breeding can occur through- vaccine are reasonably frequent, so caution
out the year, while outbreaks have occurred should be exercised especially in allergic
204 Chapter 15
persons. Repeat booster doses are necessary of any water containers, old tyres, empty
as the period of protection has not been fully tins or other small collections of water
worked out and there is some suggestion of a in which they can breed. They are daytime
shift in the age group contracting the dis- biters and can be found in large numbers
ease, in areas where vaccination has been in urban and peri-urban areas. Ae. albopic-
used for some years. tus has comparatively recently become
established in the USA, Central America
Treatment There is no treatment. and the Caribbean due to the trade in used
tyres.
Surveillance Notification of cases should be Virus is maintained in a human/mos-
reported to WHO, so that neighbouring quito cycle in many parts of the world, but
countries and visitors can take precautions. in Africa and Southeast Asia, a monkey/
mosquito cycle is involved.
15.4 Dengue Incubation period 315 days (commonly

46 days).
Organism Dengue virus has four serotypes
(1, 2, 3 and 4). Period of communicability The mosquito is
able to transmit infection for 812 days
Clinical features Dengue presents as a after taking an infective blood meal and
sudden onset of fever, retro-orbital head- remains so for the rest of its life. Humans
ache, joint and muscle pains. A maculo- and monkeys are infectious during and just
papular or scarlatina-form rash usually before the febrile period.
appears after 34 days. Depression and pro-
longed fatigue often occur following the Occurrence and distribution Dengue is now
acute manifestations. Dengue haemorrhagic endemic in many parts of the world, South
fever (DHF), in which there is profound and Central America, sub-Saharan Africa,
bleeding into skin and tissues, is now a ser- South and Southeast Asia. In more isolated
ious feature of many epidemics. communities, large epidemics have oc-
DHF is probably due to a sensitization curred, especially in the island countries of
with a previous dengue serotype, either the Caribbean and Pacific with devastating
acquired at birth or from a previous infec- effect. The epidemic can be so massive as to
tion, type 2 being the most potent and types immobilize large segments of the popula-
3, 4 and 1 being responsible in decreasing tion, disrupt the work force and cause a
importance. Differential effect on racial breakdown in organization. The develop-
groups suggests that host factors may also ment of DHF has been variable, producing
have a role, as well as the geographical a number of deaths. It is estimated that there
origin of the dengue strain. are about 50 million cases of dengue, 0.5
million cases of DHF and 12,000 deaths
Diagnosis Virus can be isolated from the due to dengue every year. Children are the
blood in acute cases or a rising antibody main sufferers of both dengue and DHF.
level may assist in diagnosis.
Control and prevention The main method of
Transmission Mosquitoes of the Aedes control is to reduce mosquito breeding, es-
group, especially Ae. aegypti, Ae. albopictus pecially of the Aedes mosquito, by depriv-
or a member of the Ae. scutellaris group ing it of collections of water or covering
are responsible for transmission. These mos- them so that mosquitoes cannot enter. All
quitoes are more easily identifiable than water tanks, pots or other containers must
most by their black colour, with distinctive be covered at all times, a recent improve-
white markings (Fig. 15.2). They like to ment being to treat these covers with insecti-
breed close to humans, taking advantage cides as it is often difficult to get a perfect fit.
Aedes aegypti
A. scutellaris A. albopictus
(group)
A. longipalpis A. africanus
A. simpsoni
Fig. 15.2. Aedes, the black and white mosquitoes.
Guttering around the roof can also allow are very effective at doing this and can be
pools of water to collect, so these should be encouraged with a marks or reward scheme.
of sufficient slope and cleaned out regularly Screening of houses and mosquito nets
so that water cannot collect. Old tyres are of little use because people are often
should have holes cut in them or removed outside their houses when the mosquito
altogether (one answer to the disposal prob- bites, but are of value for young children.
lem is to weight them and bury them at sea to ULV spraying, either by fogging or by air-
form artificial reefs). craft, is of value in the presence of an
People should check their gardens and epidemic, but only adult mosquitoes are
immediate vicinity at regular intervals to killed and are soon replaced by young adults
remove any cans, coconut shells or other unless simultaneous larval control is also in
temporary collections of water. Children operation.
206 Chapter 15
Treatment There is no specific treatment, the canopy mosquito look for another
but hypovolaemic shock must be treated blood meal and perhaps feed on humans.
with rapid fluid replacement and oxygen More commonly, it is the person who goes
therapy. into the forest to cut wood or hunt and
is bitten incidentally. When they return
Surveillance Regular checks should be made to their village or town, they are fed on
on mosquito breeding, especially of Ae. by Ae. aegypti and an urban yellow fever
aegypti. Samples should be taken and the transmission cycle is set up (see Fig. 15.3).
number of larvae breeding counted to give In Africa, three different kinds of mosqui-
an indication of the risk of transmission. toes are involved. Ae. africanus remains
Further details will be found under yellow in the jungle canopy rarely feeding on
fever. humans, but should the monkey descend to
the forest floor or even enter areas of human
habitation, it is fed on by Ae. simpsoni,
15.5 Yellow Fever Ae. furcifer-taylori or Ae. luteocephalus.
The mosquito then bites a person on the
edge of the forest, who returns to the village
Organism The yellow fever virus is a
soon to suffer from yellow fever. Fed upon
Flavivirus.
by the peri-domestic mosquito Ae. aegypti,
an urban cycle is started (Fig. 15.3). The
Clinical features One of the haemorrhagic extrinsic cycle of infection takes 530 days
group of arbovirus infections, yellow fever in the mosquito depending on temperature
presents with a sudden onset of fever, head- and type of mosquito. Trans-ovarian infec-
ache, backache, prostration and vomiting. tion can also occur.
Jaundice commences mildly at first and
intensifies as the disease progresses. Albu-
minuria and leucopenia are found on exam- Incubation period 36 days.
ination, while haemorrhagic symptoms of
epistaxis, haematemesis, melena and bleed- Period of communicability is from before the
ing from the gums can all occur. In endemic fever commences to 5 days after, so the pa-
areas, the fatality rate is low except in the tient should be nursed under a mosquito net
non-indigenous areas. The death rate may to prevent new mosquitoes from becoming
reach 50% during epidemics. infected.
Diagnosis is made on clinical grounds after Occurrence and distribution Yellow fever
initial identification of an outbreak. Virus nearly always presents as an epidemic in
can be isolated from the blood in specialist humans, affecting all ages and both sexes,
laboratories. Specific IgM in early sera or a although adults (particularly males) who go
rise in titre in paired serum can be of value, into the forest are likely to be the first
but cross-reactions can occur with other fla- to contract the disease. There are estimated
viviruses. to be 200,000 cases and 30,000 deaths annu-
ally from yellow fever, most of them in
Transmission Yellow fever is a disease of the Africa. Most cases have been reported from
forest, maintained in the monkey popula- Nigeria in recent times. Yellow fever is
tion by Haemagogus, Sabethes and Aedes restricted to the areas of Africa and South
mosquitoes in America, and Aedes in America, and Panama in Central America,
Africa. The monkeys are generally not shown in Fig. 5.1.
affected by the disease, but occasionally
start dying, indicating that spread to the Control and prevention The most important
human population may soon begin. In part of the complex mosquito transmission
South America, it may be a reduction cycle is Ae. aegypti. With its proximity to
in the monkey population that will make humans, it is capable of infecting a large
AFRICA AMERICA
Aedes africanus
Haemagogus sp.
Sebethes sp.
Aedes sp.
Jungle (sylvatic) cycle
Aedes simpsoni Rural

cycle
Urban cycle
Aedes aegypti
Fig. 15.3. Yellow fever transmission cycles in Africa and South America (including Panama).
208 Chapter 15
number of people as well as being the most Surveillance All cases of suspected or con-
easy to control. It breeds in small collections firmed yellow fever must be reported to
of water near peoples houses, so a careful WHO. The prevalence of the urban vector
search for larvae and the destruction of can be measured by the Ae. aegypti index.
breeding places can do much to reduce the This is the number of houses found with Ae.
danger. Simple clearance is the most effect- aegypti breeding within a specified area of
ive method of reducing the mosquito popu- 100 houses. Alternatively, the Breteau index
lation (see under dengue above), but can be used, which is the number of contain-
insecticides such as temephos (Abate) can ers in which larvae are found out of 100
be used where collections of water cannot be samples. If these are kept below 5% or pref-
destroyed. In the event of an epidemic, erably 1%, then the danger of an epidemic is
emergency reduction by fogging or ULV minimized.
spray from aircraft will rapidly destroy the
adult population (but not the larvae).
One attack of yellow fever confers im-
munity for life if the person survives the dis- 15.6 Malaria
ease. Inapparent infections can also occur.
A very effective vaccine has been developed Organism There are four human malaria
which provides immunity for at least parasites, Plasmodium falciparum, P.
10 years and probably longer, so all those at vivax, P. malariae and P. ovale. P.
risk in the known endemic areas should be falciparum causes the most serious disease
vaccinated (Fig. 5.1). This has been at- and is the commonest parasite in tropical
tempted by offering vaccination at markets regions, but differs from P. vivax and
and meetings or systematically to school P. ovale in having no persistent stage (the
children. WHO has now recommended that hypnozoite), from which repeat blood stage
yellow fever vaccination be included in the parasites are produced. P. vivax has
childhood vaccination programme in the 33 the widest geographical range, being found
countries of Africa in the yellow fever zone, in temperate and sub-tropical zones as
to be given at the same time as measles well as the tropics. P. vivax infection will
vaccine. In the event of an epidemic, ring lead to relapses if a schizonticidal drug
vaccination can be performed; the epidemic only is used for treatment and some strains,
is surrounded by a circle of vaccinated per- e.g. the Chesson strain in New Guinea
sons, progressively closing in on the centre of (Papua New Guinea and Irian Jaya) and
the outbreak. Areas of Africa and South Solomon Islands requires a more prolonged
America have been designated as yellow radical treatment. P. malariae produces
fever areas (Fig. 5.1) and all visitors to this a milder infection, but is distinguished
zone require vaccination. from the other three by paroxysms of
In these days of rapid air transport it fever every fourth day. P. malariae
has always been surprising that yellow can persist as an asymptomatic low-grade
fever has not been transported to Asia, parasitaemia for many years, to multiply
where there are the vectors and conditions at a future date as a clinical infection.
for transmission. A suggested reason is that P. ovale is the rarest of the parasites and is
there is some cross-immunity with other suppressed by infections with the other
Group B viruses and the level of such species.
induced immunity may be sufficient to pre- The malaria parasite reproduces asexu-
vent epidemic spread. A precaution is to ally in humans and sexually in the mosquito
spray all aircraft coming from a yellow (Fig. 15.4). A merozoite attacks a RBC, div-
fever area. ides asexually, rupturing the cell, each new-
formed merozoite attacking another RBC.
Treatment There is no specific treatment, Toxins are liberated when the cell ruptures,
but supportive therapy is given to combat producing the clinical paroxysms. After sev-
shock and renal failure. eral asexual cycles, male and female
gametes are produced, which are ingested alternating pattern of peaks of fever
when a mosquito takes a blood meal. These followed by sweating and profound chills.
go through a complex developmental cycle Classically, these take on a pattern of either
in the stomach wall of the mosquito, culmin- 3 days (tertiary malaria) or 4 days (quater-
ating in the production of sporozoites, nary malaria). However, falciparum malaria
which migrate to the salivary glands ready can present in many different forms includ-
to enter another person when the mosquito ing cerebral malaria (encephalopathy and
next takes a blood meal. coma) as acute shock, haematuria (black-
The sporozoite enters a liver cell in water fever) and jaundice.
which development to a schizont takes
place. This ruptures, liberating merozoites, Diagnosis is with a thick blood smear (to
which attack RBCs, thereby starting an detect parasites) and a thin smear (to deter-
erythrocytic cycle. In P. vivax and P. ovale, mine species) (Fig. 15.5). A dipstick method
a persistent liver stage, the hypnozoite is for P. falciparum has made the diagnosis
formed, meaning that if parasites are cleared of malaria simpler, but is still too expensive
from the blood, relapses can occur, often for routine use in many countries. It is
continuing for many years unless radical particularly useful for surveys. A similar
treatment is given. dipstick method for the other malaria para-
sites has been developed, but is not suffi-
Clinical features Infection commences with ciently sensitive or specific to replace
fever and headache, soon developing into an blood slides.
Ookinete penetrating stomach wall
Zygote
Microgamete fertilizes macrogamete
Exflagellation of
microgametocyte
Developing
oocyst Macrogamete
Rupturing oocyst liberating
sporozoites
Sporozoites enter Mosquito

salivary glands
Infective mosquito
injects sporozoites
Man Gametocytes
Pre-erythrocytic
phase
Sporozoites
enter liver cells
Developing schizont Ring form
Hypnozoite Merozoite
(in. P. vivax Trophozoite
and P. ovale)
Rupturing
schizont Erythrocytic cycle
liberating
merozoites
Schizont
Fig. 15.4. The malaria life cycle.

210
P. malariae P. ovale
P. falciparum P. vivax
Early

trophozoite
(ring form)
Late
trophozoite
Rarely seen in RBC enlarged

peripheral blood
Chapter 15
Schizont
824 nuclei
1224 (16) nuclei 612 (8) nuclei
18.11.2004 5:51am page 210

Gametocyte
Fig. 15.5. Differential diagnosis of Plasmodium spp. RBC, red blood cell.
Table 15.2. The main malaria vectors and their behaviour in relation to control.
Geographical area Anopheles species Behaviour in relation to control
More arid areas of sub-Saharan Anopheles arabiensis Feeds on animals and humans depending
Africa and Western Arabia on availability. Some exit after feeding
More humid parts of sub-Saharan A. gambiae s.s. Bites humans in the middle of the night.
Africa Rests indoors after feeding. Breeds in
temporary puddles, increasing
considerably in wet season and declining
in dry
Sub-Saharan Africa, including A. funestus Bites humans in the middle of the night.
highlands Rests indoors after feeding. Breeds in
more permanent water bodies, remaining
a constant vector throughout the year
Rural areas of Indian sub- A. culicifacies, species A, Feeds predominantly on animals, but bites
continent and Southwest Asia C, D and E humans sufficiently to be the main rural
vector in India and Sri Lanka. Tends to
bite early in the night. Breeds in water
tanks and pools, but not rice fields
Urban areas of Indian sub- A. stephensi Feeds on humans and animals throughout
continent and Southwest Asia night, except in cold weather, when biting
is early. Breeds in wells and water tanks
Indian sub-continent A. fluviatilis species S Bites humans and rests indoors.
Associated with hill streams
South and Southeast Asia A. sundaicus Mainly bites cattle, but also humans
sufficiently to be a vector. Breeds in salt-
water lagoons
Southeast Asia (including A. minimus Feeds on humans and rests indoors, but
northeast India and southwest due to prolonged insecticide spraying
China) has changed to outdoor resting and
animal biting in some areas
Southeast Asia A. dirus Bites humans indoors, but then exits.
Associated with forests
A. aconitus Lives indoors. Breeds in rice fields
Nepal, Malaysia, Indonesia A. maculatus Bites humans indoors. Breeds in rice fields
Indonesia A. leucosphyrus Bites humans and rests indoors
Philippines A. flavirostris Bites humans and rests indoors
China A. sinensis Mainly bites animals, inefficient vector
A. anthropophagus Bites humans, efficient vector. Both breed
in rice fields
Melanesia A. farauti Bites humans indoors and rests indoors
A. punctulatus, Breeds in temporary rainwater pools
A. koliensis
Central America, western South A. albimanus Bites outside and early in the night. More
America and Haiti abundant during rainy season
Central and northern South A. pseudopunctipennis Bites humans indoors
America
North urban South America A. darlingi Bites humans and rests indoors. Biting time
variable in different parts of its range.
More abundant during rainy season
Northern South America A. nuneztovari Bites humans indoors, but exits during night
A. aquasalis Bites outside and early in the night. Breeds
in brackish water
South America A. albitarsis complex Bites humans outdoors. Associated with
(A. marajoara) gold mining
Turkey, Central Asia, Afghanistan A. sacharovi, Bites humans indoors
A. superpictus
212 Chapter 15
Transmission is by Anopheles mosquitoes cannot survive, but water in the wells and
(Table 15.2). The efficiency of the vector that used for irrigation have allowed mos-
will depend upon the species of Anopheles, quitoes to breed and malaria to appear. Rain-
its feeding habits and the environmental fall generally increases the number of
conditions. This varies widely, with A. gam- breeding places for mosquitoes, so there is
biae being the most efficient of all malaria more malaria in the wet season. However,
vectors, to a species such as Anopheles culi- if the rainfall is so heavy as to wash
cifacies, which is comparatively inefficient. out breeding places, this results in a
This is determined by a number of factors, decrease of mosquitoes.
such as the preferred food source (humans The mosquito, being a fragile flyer, is
or animals), the time of biting (easier in the easily blown by the wind, sometimes to its
middle of the night when people are sleep- advantage, but generally to its disadvantage.
ing) and whether it lives inside the house or On windy evenings, mosquito biting may
outside, but the most important is the mos- decrease considerably.
quitos length of life. Only a few A. culicifa- Nocturnal mosquitoes are sensitive to
cies will survive longer than 12 days and so light; so on a moonlit night, there is a reduc-
become infective (dying before completion tion in numbers. Measurements of mosquito
of the extrinsic cycle), whereas 50% of a density must be made on several nights, or
population of A. gambiae will live longer ideally over a period of months.
than 12 days. Longer living mosquitoes are When the mosquito species is mainly
better vectors. A female mosquito must zoophilic (feeds on animals), keeping do-
have a blood meal before it can complete mestic animals in proximity to the house-
its gonotrophic cycle and lay a batch of hold will encourage mosquitoes to feed on
eggs. The gonotrophic cycle is normally them, instead of on the human occupants. It
about 23 days, but varies with temperature, is these environmental factors which deter-
species and locality. Long-living mosqui- mine whether malaria is endemic or epi-
toes will be able to lay several batches of demic. Where conditions of temperature
eggs and this is used to estimate the longev- and moisture permit all-year-round breed-
ity of a mosquito species. ing of mosquitoes, endemic malaria occurs,
Another factor is mosquito density. but if there is a marked dry season or reduc-
A large number of mosquitoes have greater tion in temperature, then conditions for
transmission potential than a few. Some transmission may only be suitable during a
mosquitoes produce large numbers at cer- part of the year, resulting in seasonal mal-
tain favourable times of the year, while aria. If conditions are marginal and only fav-
others maintain more constant populations. ourable every few years, then epidemic
The environment largely determines mos- malaria can result. Epidemic malaria is dev-
quito density. astating, as large numbers of people who
The most important environmental have no immunity are attacked. Endemic
factors are temperature and humidity, with and epidemic malaria call for entirely differ-
wind, phases of the moon and human activ- ent strategies of control.
ity having lesser effect. Temperature deter- Malaria can also be transmitted by
mines the length of development cycle of the blood transfusion, from needles and syr-
parasite and the survival of the mosquito inges, and rarely congenitally.
vector. This means that in temperate cli-
Incubation period depends upon the species
mates, malaria can only be transmitted in
and strain of the parasite:
brief periods of warm weather when the
right conditions are available. In tropical
regions, altitude alters the temperature and P. falciparum 914 days
highland areas will have less (although pos- P. vivax 1217 days, but in temperate
sibly epidemic) malaria. climates, it can be 69 months
P. malariae 1840 days
Water is essential for the mosquito to
P. ovale 1618 days
breed. In arid desert countries, the mosquito
Period of communicability is as long as there . Hyperendemic. Spleen rate in children

are infective mosquitoes. For a mosquito to constantly over 50%. Spleen rate in adults
become infective, it must live long enough also high (over 25%).
for the parasite to complete the developmen- . Holoendemic. Spleen rate in children
tal cycle (the extrinsic cycle), which constantly over 75%, but spleen rate in
depends upon the temperature and species. adults low.
P. vivax completes this more quickly than
P. falciparum. In endemic areas, the gametocyte rate is
highest in the very young, but in epidemic
Development time (days) at malaria or areas where transmission has
mean ambient temperature been considerably reduced, gametocytes
occur at all ages.
Species of parasite 308C 248C 208C Malaria is found in the tropics and sub-
tropics of the world (Fig. 15.6 and Table
P. vivax 7 9 16 15.2), mostly P. falciparum, but P. vivax is
P. falciparum 9 11 20 the predominant species in the Indian sub-
P. malariae 15 21 30
continent. It used to be more extensive with
seasonal malaria in temperate regions, but
At 198C, P. falciparum takes in excess of extensive control programmes have confined
30 days (beyond the life expectancy of an it to its present limits. However, increase in
average mosquito), whereas P. vivax can population and the development of resist-
still complete its cycle in less than 20 days. ance, both by the parasite and the mosquito,
The absolute minimum temperature for means that malaria is still the most important
P. vivax is 178C, but the extrinsic cycle is parasitic disease in the world. Each year,
longer than the lifetime of the mosquito. there are some 300 million cases out of
which over a million die.
Occurrence and distribution In a non- Global climatic change has resulted in
immune population, children and adults of an increase in epidemic malaria (infecting
both sexes are affected equally. In areas of new or infrequently involved areas) and the
continuous infection with P. falciparum, development of endemic malaria in high-
malaria is predominantly an infection of land areas, which were normally protected
children in whom mortality can be consider- by their lower temperatures (see also
able. The survivors acquire immunity, Section 1.4.7).
which is only preserved by the maintenance
of parasites in the body, due to re-infection. Control and prevention Mathematical
Should the individual leave an area of con- models were introduced in Section 2.4, mal-
tinuous malaria, immunity may be reduced. aria being one of the best examples in which
Immunity is also reduced during pregnancy, they can be used to work out the strategy for
severe malaria can occur in a pregnant control. The parasite life cycle was des-
woman, even if she has lived in an endemic cribed above and illustrated in Fig. 15.4,
area. This is worse in the first pregnancy while each of these stages can be repre-
than subsequently. sented mathematically as schematically
The body responds to malaria by an en- shown in Fig 15.7. The stages and values
largement of the spleen. The degree of en- for each of the places where the life cycle
largement and the proportion of the can be interrupted are given below:
population with palpable spleens have
been used as a measure of endemicity: 1. In humans
. Hypoendemic. Spleen rate in children . reduction of the duration of infection (1/r)

(29 years of age) not exceeding 10%. by chemotherapy;
. Mesoendemic. Spleen rate in children be- . prevention of infections with gametocytes
tween 11% and 50%. (b) by chemoprophylaxis and vaccination.
214

Hong Kong
Macao
Brunei Darussalam
Cape Verde Singapore
Chapter 15
Singapour
Cap-Vert
Maldives
Comoros
Comores
Vanuatu
Mauritius
Maurice
Areas in which malaria has disappeared, been eradicated
18.11.2004 5:51am page 214

or never existed
Areas with limited risk
Areas where malaria transmission occurs
World Health Organization 1991

Organisation mondiale de Sant 1991
Fig. 15.6. The occurrence of malaria in the world. (Reproduced by permission of the World Health Organization, Geneva.)
2. In mosquitoes Each of the parameters can be given

values that have been measured in the field
. prevention of human biting (a a a2) by so that the level of control required to inter-
personal protection and mosquito nets; rupt transmission can be calculated (reduce
. decreasing mosquito density (m) with lar- the basic reproductive rate below 1).
viciding and biological control; Some useful modifications of the for-
. reduction of the proportion surviving to mula are the
infectivity (pn) by residual insecticides
and treated mosquito nets; ma2 pn
. reduction of the mosquito expectation of Vectorial capacity
r(ln p)
life (1/ln p) by knock-down and residual
insecticides. and the critical density of mosquitoes below
which the infection will die out given by
(p is the probability of a mosquito surviving
through 1 day, n the time taken to complete r(ln p)
the extrinsic cycle, and ln the natural loga- a2 bpn
rithm.)
The complete formula becomes More complex models have been de-
veloped to overcome some of the shortcom-
ma2 bpn ings of this model, such as the development
z0
r(ln p) of immunity, but even in this limited form, it
is very valuable.
where z0 is the basic reproductive rate (see The effectiveness of any potential strat-
Section 2.2.3). egy can be estimated from the algebraic
Mosquito
Expectation of life Oocyst
1 Proportion
pn surviving to
ln p
infectivity
Human-biting habit
a Sporozoite a m
Parasite
Gametocyte Mosquito
density
Human-biting
habit
Infection lasts
b
1
days
g
Trophozoite
Infections produced
(with gametocytes)
Human
Fig. 15.7. Mathematical model of malaria based on the schematic life cycle of the parasite.
216 Chapter 15
expression given to each part of the formula and repellents. Items of clothing, such as
without making any calculations: socks and shawls, can be treated with repel-
lents, which retain activity for some time, or
. 1/r the duration of infection reduced by repellents can be applied directly to the
chemotherapy, demonstrates the small skin. Some naturally occurring plants have
effect of just treating malaria cases, and repellent properties, such as African mari-
that control efforts, such as MDA used in golds (Tagetes minuta).
malaria eradication programmes, need to Mosquito nets are most effective if
be total, covering every single person, vir- used properly. Providing subsidized mos-
tually impossible to achieve. quito nets can help in malaria control,
. b this is actually a notation normally especially for mothers and children, who
applied to mosquitoes, being the propor- are liable to go to bed early (before mosquito
tion that ingest gametocytes so that the biting starts). This can be improved by
parasite sexual cycle can take place, but treating the nets with synthetic pyrethroid
can be applied to the human part of insecticides (such as permethrin, deltame-
the cycle as any method which prevents thrin, alpha-cypermethrin or lambda-
the production of gametocytes. This can cyhalothrin). This repels mosquitoes and
either be by preventing infection in the kills those which come into contact with
first place with vaccination or chemopro- the net. When used on a community scale,
phylaxis, the use of gametocidal drugs, or the concentration of insecticide-treated
preventing the mosquito feeding on a mal- mosquito nets (ITMN) can produce a mass
aria case by keeping them under a mos- effect reducing the mosquito population and
quito net. However, b is only a unitary the sporozoite rate. The method of treating
factor, so all of these methods will need mosquito nets will be found in Section 3.4.1.
to be nearly perfect to work. A recently introduced technology is the
. a the number of bites that need to be manufacture of mosquito nets with the in-
made by the mosquito. One bite is needed secticide already in the net, known as long-
to introduce infection and another to take lasting insecticidal nets (LLIN). These retain
up gametocytes, so the interruption of activity for at least 4 years, so the regular re-
mosquito biting could be quite an effect- treating of nets can be avoided; hence this
ive strategy. Therefore, personal protec- holds considerable potential as the main
tion with clothing, repellents and method of malaria control.
mosquito nets is a valuable method of Mosquito bed nets are more effective
control. and cheaper to maintain than screening the
. m the density of mosquitoes is only a whole house, which is only recommended
unitary factor demonstrating the poor for people with a high standard of living.
results of larviciding and biological A small hole in the netting can render it
methods in malaria control. ineffective. A knock-down spray can be
. p mosquito survival consists of two used to kill mosquitoes that have entered a
factors, its expectation of life (short-lived screened house.
vectors are poor transmitters) and the The use of smoke from mosquito coils or
number of mosquitoes living long enough vaporizing mats can be surprisingly effect-
to complete the extrinsic cycle. In this p is ive and has the advantage that it is a cheaper
raised to the nth power showing that option for personal protection. Coils are
reducing the length of life of the mosquito easily manufactured locally and naturally
(mainly by the use of insecticides) is the occurring substances, such as pyrethrum,
best control strategy. are incorporated. People often sit around
fires in the evening and by the addition
of certain plants, a repellent smoke can be
PERSONAL PROTECTION Methods of personal produced.
protection have been covered in Section Mosquitoes can be deviated to bite other
3.4.1. They include clothing, mosquito nets animals if they are the preferred blood meal;
however, if the animals are taken away, such that once done, it lasts for a long period of
as to market, then the mosquitoes may be time, if not permanently, and in these days
forced to take their blood meal from of resistant mosquitoes, it is seen as an eco-
humans. The habits of the malaria vectors nomical proposition in some circumstances
will need to be known before encouraging (see also Section 3.4.1).
this practice. Biological control with fish or bacilli
(Bacillus thuringiensis or B. sphaericus)
will reduce mosquito larvae to a certain
RESIDUAL INSECTICIDES The use of residual
extent, but a balance, as with much of
insecticides has been covered in Section
nature, often results. Biological control can
3.4. These are applied to the inside surface
also be used directly against adult mosqui-
of houses so that the resting mosquito (after
toes with the sterile male technique. This
it has taken its blood meal) absorbs a lethal
has not been successful with mosquitoes
dose of insecticide and dies before the para-
because of the very large numbers involved
sites it has taken up in the blood can com-
and their short period of life. Another
plete development. This was the main
method that is being considered is species
method of the malaria eradication pro-
competition whereby a non-malarial mos-
grammes used in many countries of the
quito from another part of the world is intro-
world. Unfortunately, insecticidal resist-
duced to compete with the resident vector.
ance, organizational breakdown and reluc-
This has not met with any great success.
tance by people to have their houses
In epidemic malaria, using a fogging
sprayed, resulted in an abandonment of the
machine or ULV spray from aircraft can rap-
goal of eradication. This has been replaced
idly reduce adult mosquito density. This
by a policy of malaria control in which
will cut short the epidemic by killing off
house spraying may be a component.
flying adults, but needs to be repeated regu-
larly as new adults will continually be
LARVICIDING AND BIOLOGICAL CONTROL The produced from larvae that are not affected
number of larvae determines the density of by the knock-down sprays.
mosquitoes, so any method which reduces
the larval numbers inadvertently reduces CHEMOPROPHYLAXIS Attempts to use chemo-
the potential number of adults. The larvae prophylaxis on a large scale on pregnant
can be attacked by several different women and young children have not met
methods: with much success, but could be given to
persons at particular risk, such as non-
. using insecticides and larvicidal sub- immune immigrants or migrant workers.
stances; Chloroquine 300 mg (two tablets) weekly
. modification of the environment; can be used where chloroquine resistance
. biological control. is not a major problem, but local advice
should be sought. It is preferable to give
Larvicidal substances can be oils that spread pregnant women and young children prior-
over the surface and asphyxiate the larvae or ity in the distribution of ITMN or LLIN, or to
have insecticidal properties. The size and use chemoprophylaxis in combination with
flow of the body of water will determine them.
which is the preferred method to use. Modi-
fication of the environment by drainage or REDUCING THE NUMBER OF GAMETOCYTE Qui-
filling-in is the most permanent and effect- nine, chloroquine and amodiaquine are
ive, but is an expensive undertaking. It is active against the gametocytes of P. vivax
worth spending money on engineering and P. malariae, but not against the more
methods in areas of dense population, such important P. falciparum. Proguanil and pyr-
as towns, while in rural areas, much can be imethamine act on the development of gam-
achieved by using self-help schemes. The etocytes within the mosquito on all four
considerable advantage of this method is parasites. Primaquine has a highly active
218 Chapter 15
and rapid action on gametocytes of all sible people is likely to be more successful
species, whether in the blood or mosquito in the long term than more complex
and is used in combination with treatment methods.
in the individual. It has also been proposed
as a method of reducing the level of gameto- Treatment of the uncomplicated case of
cytes within the population, but would P. vivax, P. malariae and P. ovale malaria is
require an almost perfect mass treatment as with chloroquine:
well as the danger of toxicity (especially
with G-6-P-D deficient individuals), and
. 600 mg of chloroquine base as an initial
therefore, is not considered a suitable
dose;
method of malaria control.
. 6 h later, 300 mg chloroquine base,
Any person found to have malaria
followed by
should, where possible, be protected by
. 300 mg chloroquine base for 3 or more
a mosquito net so as not to infect new mos-
days.
quitoes. This is a particularly important
measure during eradication and control
campaigns, especially when endemicity is Chloroquine-resistant P. vivax has been
brought to a low level. reported from Western Pacific Islands,
including the island of New Guinea, as
VACCINES Attempts to produce a vaccine well as Guyana in South America.
against malaria have been in progress since P. falciparum is resistant to chloroquine
1910. A vaccine made from killed sporozo- and many other anti-malarial drugs, so indi-
ites by irradiating mosquitoes is reasonably vidual countries will have their own treat-
effective, but cannot be produced on a large ment schedules depending on the resistance
scale. Easier to produce are vaccines made pattern and the drugs available. Quinine,
by isolating the DNA fragments of the cir- mefloquine, artemether, artesunate, artemo-
cumsporozoite antigen and cloning them til, chlorproguanil/dapsone (LAPDAP) and
through bacteria or yeasts. This has allowed artemesin-based combination therapies
large quantities of pure antigen to be pro- (ACTs), such as artemether/lumefantine are
duced and trials of candidate vaccines. available. Artesunate in single-dose rectal
Unfortunately, the response has been suppositories is a new approach to treating
limited, so current research is to use a malaria in children, who are not able to take
prime-boost technique similar to that for medicines orally.
HIV. However, even if a vaccine is de- In P. vivax, chloroquine will only clear
veloped, all the problems of vaccination parasites from the blood, and to effect rad-
programmes, such as coverage, administra- ical cure, primaquine is administered in a
tive difficulties and response of the public dose of 15 mg base daily for 14 days (except
(see Section 3.2) will remain. in the island of New Guinea and other West-
ern Pacific Islands, where more prolonged
PROSPECTS FOR MALARIA CONTROL Malaria at- treatment is required).
tracts the wonder cure first, it was the Case finding and treatment is an effect-
eradication programme, now all hope is ive strategy where there is a low level
pinned on the vaccine, but it is more likely of malaria, so it needs to be used in combin-
to be controlled by simple, non-dramatic ation with other methods of malaria control.
methods where care to detail is applied. It
is the encouragement of simple protective Surveillance In all areas where malaria is
methods that everybody can follow like found, a blood slide should be taken from
ITMN (or LLIN) or community action to anyone with a fever. Where attempts are
modify the environment to make it unsuit- being made to eradicate or reduce the level
able for mosquitoes to breed (see Table 15.2 of malaria, then an active system of surveil-
for the main vectors). A multiplicity of lance may be instituted as described in
simple methods carried out by many respon- Section 4.5.2.
Where a control method is in operation, microfilariae are liberated into the lymph-
regular checks should be made, such as the atic stream, reaching blood vessels via the
proportion of houses with ITMN and thoracic duct.
the number of people sleeping under them. The parasite times its production of
More will be found on malaria programmes microfilariae to coincide with the biting
in Sections 4.34.5. time of the vector mosquito, a phenomenon
called periodicity. Mostly this is a nocturnal
cycle, with a peak at around midnight, but
can also be diurnal, or in the Central and
15.7 Lymphatic Filariasis Eastern Pacific Islands, it is aperiodic with
similar levels of microfilariae being found
Organism Wuchereria bancrofti, Brugia throughout the 24 h period.
malayi and B. timori, nematode worms. Microfilariae live for about 6 months
Microfilariae, the larval form present in the and adult worms for 712 years although
peripheral blood, are taken into the mosqui- they probably only produce microfilariae
tos stomach when it feeds on humans (or for 23 years.
animal reservoir in B. malayi). The larva
loses its sheath inside the mosquito, mi- Clinical features In the body, the larva
grates through the stomach wall and reaches the lymphatics and settles down in
burrows into the muscles of the thorax. It a lymphatic node to develop into an adult. It
becomes shorter and fatter, commonly de- is the obstruction of the lymphatic drainage
scribed as sausage-shaped. Developmental system by the adult worms, especially the
changes take place and it elongates to a fibrotic reaction when they die, that causes
third stage infective larva. Leaving the the series of disease manifestations. A range
thoracic muscles, it migrates to the probos- of conditions result, including fever,
cis where it waits for the mosquito to feed. lymphangitis, lymphoedema, hydrocele,
Forcing its way out of the proboscis, it falls elephantiasis and chyluria. Night sweats
on to the skin, finding a way into the tissues, are a common early indication of infection,
generally through the wound made by the with high eosinophilia count found in the
mosquito (Fig. 15.8). (It is important to real- blood. An allergic reaction, tropical pul-
ize that the infective larvae are not injected monary eosinophilia syndrome can also
like the malaria parasite.) This developmen- result. Although the signs and symptoms
tal stage in the mosquito from the time of are diverse and variable, in an endemic
the blood meal until re-infection takes area, they are often known and a blood
1121 days (average 15 days) at an optimum sample will soon confirm the diagnosis.
temperature of 26278C (extremes are
17328C), a very similar length of time to Diagnosis used to be by finding microfilar-
the development of Plasmodium. iae in a measured sample of blood using a
When the larva breaks out of the mos- thick blood smear, counting chamber or
quito to enter the skin, it is a very precarious filtration technique, taken during the peak
time for the parasite and only 2040% are microfilarial output, which generally means
successful. No multiplication takes place in collecting samples at night time. These
the mosquito, so the single larva that was laborious methods have now largely been
taken up in the blood meal becomes a single replaced by circulating filarial antigen
adult in the human. However, many larvae (CFA) detection, either based on ELISA or
are lost with only about one in 700 succeed- an immunochromatographic card. However,
ing. Since there are male and female worms, the card test only diagnoses positive or nega-
it is necessary for the two sexes to meet if the tive, while the ELISA is semi-quantitative,
female is to be fertilized. Many are unsuc- so where full quantitative measures are re-
cessful as a result of competition between quired, measured blood sample methods
males, so the intensity of infection will will still need to be used. This will be the
determine the outcome. Once fertilized, case in assessing control programmes, as a
220 Chapter 15
Pharyngeal
armature
Third-stage larva Microfilaria

Lymphatic and
adults Blood-vessel
Periodicity
Fever, lymphangitis,
chyluria, etc.
Hydrocele
Elephantiasis
Fig. 15.8. Life cycle and clinical features of lymphatic filariasis.
decrease in the number of microfilariae terns of infection and as a result, different

occurs before conversion to negativity. CFA strategies for control (Table 15.3). If Anoph-
detection is also not available for B. malayi eles mosquitoes are the vectors, they are
or B. timori. Different microfilariae need to nearly always the same vectors as those
be differentiated as seen in Fig. 15.9, as sev- that transmit malaria, so the mosquito
eral filarial infections may be present in the might well have a double infection or its
same locality. expectation of life affected by being parasit-
ized by filariasis and/or malaria.
Transmission is by both culicine and ano- As the microfilaria is quite large and
pheline mosquitoes producing different pat- causes damage to the mosquito when it
Microfilaria found in peripheral blood Microfilaria found in skin
Sheathed Non-sheathed

Nocturnal periodicity Diurnal periodicity No perodicity
Wuchereria bancrofti Brugia malayi Loa loa Onchocerca volvulus
Sheath stained pink by Sheath stained red by Sheath not stained by
Giemsa stain Giemsa stain Giemsa stain
10 m
Kinked curves
Graceful curves Kinked curves Spatulate head
Small, round Large, oval
Large, oval
discrete nuclei overlapping
overlapping nuclei
nuclei
No nuclei
at tip of tail 2 separate nuclei
at tip of tail Nuclei to tip of tail
No nuclei at tip of tail
18.11.2004 5:51am page 221

Size 210320 7.510 m Size 170260 5 6 m Size 230300 7.510 m Size 280330 69 m
Fig. 15.9. Differential features of microfilariae of medical importance. (Courtesy: Department of Medical Parasitology, London School of Hygiene and Tropical
Medicine.)
221
222 Chapter 15
bores into the thoracic muscles, the more dies out. In reality, the number of microfilar-
microfilariae it ingests the more likely it is iae will decrease below E, mosquitoes will
to be killed by a heavy infection. (In Culex survive sufficiently to transmit again and
and Aedes mosquitoes, this occurs when the the level will approach E, or the level of
microfilarial density exceeds 50 per 20 mm3 equilibrium, again. This is always the case
of blood.) This is seen in Fig. 15.10 at with culicine transmission, but in the
point E for both culicine mosquitoes bottom figure, it will be observed that there
(upper figure) and anopheline mosquitoes is also a lower point I below which transmis-
(lower figure). The line P represents the sion is not sustained for anopheline mosqui-
equilibrium level (basic reproductive level toes. In other words, at low levels of
of 1), whereby above the line, transmissions microfilariae, the anopheline mosquito
will increase and below it, infection will die seems to be able to prevent itself from be-
out; so when infection is excessively heavy, coming infected. This is probably due to the
mosquito mortality occurs and the infection pharyngeal armature in anopheline mosqui-
Table 15.3. The vectors of lymphatic filariasis. (A., Anopheles; Ae., Aedes; C., Culex; M., Mansonia;
O., Ochlerotatus.)
Geographical area Species transmitting W. bancrofti Species transmitting B. malayi
West Africa, rural A. gambiae, A. funestus,

East Africa, A. arabiensis, A. melas,
Madagascar A. merus
Urban East Africa C. quinquefasciatus
Egypt C. pipiens molestus
India, Sri Lanka and C. quinquefasciatus, A. minimus, M. amulifera, M. indiana, M. uniformis,
Maldive Islands Ae. niveus, O. harinasutai M. annulata, M. bonneae, M. dives
China Ae. togoi, A. sinensis, Ae. togoi, A. lesteri, A. sinensis,
A. anthrapophagus A. anthrapophagus
Vietnam A. jeyporiensis
Rural Thailand O. hariniasutai M. annulata, M. bonneae, M.
uniformis, M. indiana
Malaysia A. letifer, A. whartoni, M. annulata, M. annulifera,
A. maculatus, A. dirus, M. bonneae, M. dives, M. uniformis,
A. donaldi, A. letifer, A. campestris, A. donaldi
A. maculatus
Indonesia A. balabacensis, A. leucosphyrus, M. annulata, M. bonneae, M. dives,
A. maculatus A. barbirostris (B. timori)
Philippines M. dives
New Guinea (PNG A. farauti, A. punctulatus,
and Irian Jaya) A. koliensis, C. annulinostris,
C. bitaneniorhynchus,
M. uniformis
New Caledonia Ae. vigilax
Fiji Ae. polynesiensis, Ae. fijiensis, Ae.
pseudoscutellaris,
Ae. oceanicus
Polynesian Islands Ae. polynesiensis, Ae. samoanus,
Ae. upolensis, Ae. kesseli, Ae.
tutuilae, Ae. tabu, Ae. cooki
Northeast Brazil C. quinquefasciatus
y
Limitation P
(culicine transmission)
Infective larvae
Microfilaria ingested
E x
y
Facilitation
(anopheline transmission) P
Infective larvae
Microfilaria ingested
E x
Fig. 15.10. The dynamics of culicine- and anopheline-transmitted filariasis. (Reproduced, by permission,
from Pichon, G., Perrault, G. and Laigret, J. (1975) Rendement parasitaire chez les vecteurs de filarioses.
(WHO/FIL/75.132), World Health Organization, Geneva.)
toes which damages microfilariae. When when density of microfilariae is excessive,

there are many microfilariae ingested by so the chronic, long-term pattern is more
the mosquito, a sufficient quantity will common.
remain undamaged to produce infection,
but at low microfilariae levels, every micro- Incubation period From infection to the de-
filaria will be damaged. This applies to both velopment of adult worms is about 1 year, but
W. bancrofti and B. malayi, so for control, the first symptoms may not occur until
the type of mosquito is more important than microfilariae are produced (fever) or worms
the species of parasite. die (lymphatic obstruction).
Filarial infection is determined by the
number of infected bites, which can either Period of communicability Since many
be the result of a high intensity over a short infective bites are required to produce infec-
period of time or constant bites over a long tion in humans, there will need to be a
period of time. Mosquito mortality occurs continuous supply of infected mosquitoes.
224 Chapter 15
The development cycle in the mosquito enters the host, so the disease process and its
is 1121 days (mean 15 days). The infected severity depends upon repeated entry of
person can continue to produce microfilar- parasites into the body, many of which will
iae for more than 10 years, although the be unsuccessful. The transmission process
maximum output is in the first 3 years. is surprisingly inefficient, requiring some
15,500 infected bites to produce a reprodu-
Occurrence and distribution Only humans cing adult. This means that for Anopheles
are infected with W. bancrofti, but an animal mosquitoes, approximately eight bites per
reservoir exists for B. malayi in monkeys, person per day can take place without the
cats and several other animals. All races, disease being transmitted.
both sexes and all ages of persons are equally The number of bites can be reduced by
susceptible to infection. (There are marked taking simple precautions of personal pro-
differences between individuals developing tection mosquito nets, repellents, protect-
elephantiasis, but these are immunological ive clothing, etc. ITMN or LLIN should be
rather than ethnic.) effective in nocturnally periodic filariasis,
Three types of filariasis are seen rural transmitted by anopheline mosquitoes.
filariasis transmitted by nocturnal Anoph- This would be an additional benefit of a
eles mosquitoes with a generalized distribu- malaria control programme.
tion similar to that of malaria, urban filariasis
transmitted by Culex, with a tendency to
DECREASING THE NUMBER OF MICROFILARIAE (MASS CHE-
invade new areas, and the Polynesian
MOTHERAPY) Mass drug treatment is the
Island variety, which has a homogenous
main method used in the filariasis elimin-
(rural) distribution, but is transmitted by
ation programme, given as an annual single
day-and-night biting Aedes mosquitoes.
dose treatment to all the population for at
W. bancrofti is found in the tropical
least 5 years, preferably 7 years. Two
regions of the world, but with only a few
regimes are used:
foci in South America and the Caribbean.
B. malayi is restricted to East and Southeast
Asia, overlapping with W. bancrofti in part . albendazole 400 mgDEC 6 mg/kg, or
of its range. B. timori is only found in the . albendazole 400 mg ivermectin
islands of Timor, Flores, Alor and Roti 150200 mcg/kg.
(Fig. 15.11). There are more than a billion
people at risk in 80 countries. An alternative is to use diethylcarbamazine
(DEC)-fortified salt (or fortified soy sauce in
Control and prevention A similar process to China) for 612 months, if total compliance
that used for malaria for identifying the best can be assured. DEC cannot be used in an
strategies for control can also be applied to area that also has onchocerciasis.
filariasis. The various places at which con- This strategy is likely to work in areas
trol can be implemented are: in which filariasis is transmitted by Anoph-
eles mosquitoes, if the number of microfilar-
. reduction of the number of infective bites iae can be maintained below the critical
by mosquitoes; threshold (I in Fig. 15.10). One estimate sug-
. decreasing the number of microfilariae in gests that this level is about 12 microfilariae/
the human host; 60 mm3. However, as the Anopheles is also a
. reduction of the mosquitos expectation of vector for malaria, reducing the number of
life; parasitizing microfilariae, which cause
. decrease the mosquito density; damage to the mosquito, will increase the
. alteration of the mosquito biting time; mosquitos expectation of life and improve
. reduction of the number of adult worms. its chance of transmitting malaria. Precau-
tions should, therefore, be taken at the same
REDUCING THE NUMBER OF INFECTIVE BITES Multi- time to prevent this from happening by the
plication does not take place when the larva use of ITMN or LLIN.
In areas in which culicine mosquitoes malaria control and has also been covered
are the vectors, it is unlikely that MDA alone in the section on vector control (Section
will succeed in eliminating filariasis, as can 3.4.1). Various methods can be used, such
be seen in Fig. 15.10 and from past experi- as larvicides, genetic modification, environ-
ence in control programmes in Samoa and mental or biological control. These methods
Tahiti. Control of the mosquito also needs to are particularly appropriate to culicine-
take place, a simple strategy being the use of transmitted urban filariasis, although the
expanded polystyrene beads, as was used in degree of larval reduction required is often
latrines in Zanzibar and soakage pits in difficult to achieve. In enclosed areas of
South India (see also below). water, such as latrines and septic tanks,
Before mounting a mass drug treatment expanded polystyrene beads arevery effective.
control programme, a complete survey is B. malayi is transmitted mainly by Man-
needed. Follow-up surveys of samples of sonia and Anopheles mosquitoes, the
the population are made at annual intervals. Mansonia being particularly difficult to con-
Thirty percent of the treated population trol because the larvae attach themselves to
should be sampled. Children less than the underside of water plants (especially
1 year of age, pregnant and nursing mothers, Pistia), where they are immune to surface
the sick and the very old should be excluded oils and larvicides. Removal of these water
from mass treatment. Side-effects, espe- plants by hand or with herbicides has had
cially itching, can be most unpleasant and some effect.
a pilot control study should precede the
main campaign. Considerable care should ALTERATION OF MOSQUITO BITING PATTERN The
be taken in areas where both filariasis and parasite has developed a periodicity of its
onchocerciasis co-exist. microfilariae which coincides with the
biting pattern of the vector mosquitoes. If
REDUCTION OF THE MOSQUITOS EXPECTATION OF LIFE it is possible to alter the time mosquitoes
(VECTOR CONTROL) By reducing the lifespan bite, then the chance of them taking up
of the mosquito to below that of the devel- microfilaria will also be reduced. This has
opmental period of the parasite within the happened in some places due to the pro-
mosquito (range 1015 days), transmission longed use of residual insecticides and
of infective larvae will be halted. This can although it is probably not possible to utilize
be done by spraying residual insecticides this as a main control method, it could be of
inside houses or by treating mosquito nets. subsidiary value.
Where the same vectors transmit both
malaria and filariasis, then a joint control REDUCTION OF THE NUMBER OF ADULT
programme is cost-effective. ITMN or LLIN WORMS Unfortunately, there is no spe-

are particularly suitable for filariasis con- cific drug which kills adult worms, although
trol, where there is an anopheline vector DEC causes substantial mortality, a valuable
and could be used as the only strategy or secondary action to killing microfilariae.
combined with MDA (see above). The The worms lie embedded in the lymphatics
degree of mosquito reduction required is so cannot be removed surgically, as prac-
much less for filariasis than it is for malaria; ticed in onchocerciasis control.
however, mosquito control needs to be for a Adult worms live for approximately
prolonged period, at least for 7 years and 10 years (range 712 years), so if re-infection
preferably for 10 years. can be prevented for this period, they will
die off and there will be no reservoir of
DECREASE MOSQUITO DENSITY (LARVICIDING) The infection. It is maintaining control methods
number of mosquitoes able to bite man is de- for this period of time that is crucial with
pendent upon the number of larvae filariasis.
that develop into adults, so by reducing the
number of larvae, mosquito density is also di- Treatment for established elephantiasis
minished. This is a supplementary method of is unsatisfactory with mutilating surgical
226

(a)
Chapter 15
Dominican Republic
Haiti
Trinidad & Tobago

Known
Guyana northern limit
Costa Rica Surinam
18.11.2004 5:51am page 226

(excluding
Egypt)
Known or
suspected
southern limit
Foci with
higher
Brazil prevalence
WHO 92353
(b)

W. bancrofti
Circled areas where
detail cannot be shown
B. malayi
Unshaded areas where
scattered transmission
may occur B. timori
Former area (said to be
much diminished or
eradicated)
18.11.2004 5:51am page 227

WHO 92354
Fig. 15.11. Distribution of the lymphatic filariases. (Reproduced by permission, from WHO (1992) Lymphatic Filariasis: Fifth Report of the WHO Expert Committee on
Filariasis. World Health Organization, Geneva, pp. 34.)
227
228 Chapter 15
procedures. If discovered in its early stages Transmission The vector Simulium, also
of intermittent swelling, before tissue called the black fly, breeds in fast-flowing
damage has occurred, then pressure ban- streams where it is found in large numbers.
dages can prevent gross elephantiasis from The female fly attaches its eggs to the leaves
developing. In B. timori, repeat doses of DEC of water plants on which they develop.
reduce lymphoedema and to a certain extent The larvae require high oxygen levels, so
elephantiasis. are found only in fast-flowing water
(Fig. 15.12). The fly has a painful bite and
Surveillance Hydrocele or lymph node is persistent making it a considerable nuis-
surveys can be of value in rapidly defining ance, but it is also a powerful flier and
the area of filariasis. Detailed blood surveys assisted by the wind can travel up to
are then made. 100 km in search of a blood meal.
The Simulium vectors and their usual
breeding places are listed in Table 15.4, the
15.8 Onchocerciasis African flies preferring to bite the lower body,
whereas the South American flies attack the
upper part of the body. Although they can fly
Organism Onchocerca volvulus, a nematode
great distances, maximum density is at the
worm that has a predilection for the skin
breeding place, resulting in focal infection.
and eye, is transmitted by Simulium
They are outdoor, daytime biters, but each
flies. Microfilariae are taken up by the fly
species prefer different times of day to seek
when it bites humans and then undergo
their blood meal. South American Simulium
larval changes within the thoracic muscles,
have pharyngeal armatures, whereas African
migrating to the head of the fly as infective
species do not, but mortality due to super-
larvae. When the fly bites again, microfilar-
infection by Onchocerca is not important.
iae break out on to the skin to enter via
The adult flies live for 23 weeks (with a max-
any abrasion, especially the bite wound.
imum of 3 months), but prefer to feed on
animals rather than humans. However,
Clinical features The microfilariae as they people need to collect water so it is when
migrate through the skin cause itching they have to come to the river, to wash or
and damage resulting in skin changes, collect drinking water that they stand the
such as hanging groin and discoloration, greatest chance of becoming infected.
the so-called leopard skin. They migrate O. volvulus only infects humans (and
through the skin and also enter the eye, epidemiologically insignificant chimpan-
where the reaction caused by their death zees and gorillas). Eye and skin pathology
leads to eye damage, the person in the is related to the proximity of the nodules, so
course of time becoming blind, giving when there are more nodules on the upper
onchocerciasis its other name river blind- part of the body, there is a higher prevalence
ness. of blindness. In Africa, the savannah infec-
tion produces more blindness than that ac-
Diagnosis is made by taking skin-snips, quired in forests.
which are placed in saline and the liberated Microfilariae are found only in the skin,
microfilariae identified (Fig. 15.9). Taking a high density leading to the more severe
a measured area of skin with a special clinical manifestations as well as producing
punch allows density measurements to be greater opportunity to infect flies. They sur-
made. A slit-lamp examination of the eye vive for up to 2.5 years and have a periodic
may reveal microfilariae in the anterior cycle with a peak at 16001800 hours, but
chamber or characteristic eye damage. The this is relatively unimportant.
adult worms live in palpable nodules in
the skin, so their presence and character- Incubation period is prolonged, normally
istic skin changes can suggest a clinical taking about 1 year for symptoms to start
diagnosis. following infection.
(a)
1 mm
(b)
Fig. 15.12. Simulium the vector of onchocerciasis. (a) Adult. (b) Larvae and a pupa attached to a water plant,
the stream flowing in the direction of the arrow.
Period of communicability is for some most westerly part of the region covered by
1617 years, adult worms producing micro- the Onchocerciasis Control Programme (see
filariae into old age. Simulium becomes below).
infective after 613 days, depending on Repeat infection and progressive
temperature. damage from dying microfilariae means that
blindness is more common in adults, chil-
Occurrence and distribution Onchocerciasis dren then having to lead them around until
is found only in tropical Africa, Yemen and their turn to become blind. Because of these
in South and Central America, with well- severe consequences, abandonment of good
marked foci in much of this area (Fig. village sites close to rivers has frequently
15.13). In West and much of Central Africa, resulted, although control programmes
the infection is more widespread with the have largely reversed this trend.
230 Chapter 15
Table 15.4. Simulium (S.) vectors of onchocerciasis. CAR, Central African Republic.
Geographical area Species Breeding place Habitat
West Africa, CAR, Sudan, S. damnosum Large rivers Savannah, but

Uganda, Ethiopia, (Yemen?) species complex sometimes forest
West Africa, CAR, Sudan S. sirbanum Large rivers Savannah
West Africa, CAR, Congo S. squamosum Small to medium-sized Forest savannah,
rivers in hilly areas mosaic
West Africa S. soubrense Large rivers Forest, savannah
West Africa S. sanctipauli Large rivers Forest
West Africa S. yahense Small watercourses Forest
Cameroon, CAR, Tanzania S. mengense Large rivers Forest
Congo, Burundi, Uganda, S. kilibanum Large rivers Forest
Tanzania, Malawi
Congo, Burundi, Rwanda, S. naevi species Heavily shaded small Forest
Uganda, Sudan complex permanent rivers in forest
Ethiopia S. ethiopiense Heavily shaded, small Forest
permanent rivers in forest
Tanzania S. woodi Heavily shaded, small Forest
permanent rivers in
forest
Guatemala, Mexico S. ochraceum Small mountain streams Highlands
Guatemala, Mexico, S. metallicum Small streams Highlands
Venezuela
Colombia, Ecuador, Venezuela S. exiguum Large rivers Lowlands
Brazil, Venezuela S. guianense Large, fast-flowing rivers Highlands
Brazil, Venezuela S. oyapockense Large rivers Lowlands
Control and prevention Similar to lymphatic difficulty with larviciding is to ensure that
filariasis, various approaches to control can every water course is treated. Owing to
be tried. These are: the flies ability to cover large distances,
re-colonization soon takes place when in-
. reducing the fly density; secticidal applications are discontinued.
. avoidance of fly breeding places; Although expensive, the extra cost of using
. reducing the microfilarial density; aircraft and helicopters can be justified if
. reduction of the number of adult worms; many water courses, spread over large areas
. reduction in the number of Simulium of countryside, have to be covered.
bites. Unfortunately, insecticidal resistance
has occurred in a number of areas, so bio-
REDUCING THE FLY DENSITY (LARVICIDING) The logical control with B. thuringiensis is an
larvae breed in water, so insecticide is alternative. This does not have the spread-
sprayed on streams and rivers. The larvae ing power of insecticides and greater con-
are relatively sensitive to insecticides so centrations need to be used (in the order of
low-dose applications, 0.050.1 mg/l are 0.9 mg/l) and has to be mixed with water
effective. Temephos (Abate) is suitable as it before it can be applied.
is effective in a very low dose, is relatively
non-toxic to fish and retains some residual AVOIDANCE OF FLY BREEDING PLACES Maximum
action. It exerts its effect for some 2040 km contact between humans and flies occurs
downstream in the wet season. The main near rivers where Simulium breed, but
0

(a)
0
18.11.2004 5:51am page 231

Endemic onchocerciasis
Area covered by the OCP
10E WHO 94910
Fig. 15.13. Distribution of onchocerciasis. (a) Africa and Yemen. Continued Overleaf.
231
232
(b)

Mexico Mexico
1 2
Guatemala
3
4
5
6 7
Chapter 15
9
Endemic onchocerciasis
Venezuela
1. Oaxaca focus
2. Northern Chiapas focus
3. Southern Chiapas focus
4. Huehuetenango focus
5. Solola Suchitepequez focus 10 11
6. Escuintla focus 12 Colombia
7. Santa Rosa focus
8. Northcentral focus 13
9. Northeastern focus
18.11.2004 5:51am page 232

10. Southern focus
14
11. AmazonasRoraima focus
12. Lpez de Micay focus Ecuador
13. Nario focus
14. Esmeraldas focus Brazil
WHO 94911
Fig. 15.13 (contd ). Distribution of onchocerciasis. (b) the Americas. OCP, former Onchocerciasis Control Project area. (From World Health Organization Technical
Report Series (1995) Onchocerciasis and Its Control, No. 852. Reproduced, by permission of the World Health Organization, Geneva.)
these can be avoided by providing alterna- tained for this length of time before eradica-
tive water sources, such as wells or a piped tion can take place. However, most
supply to nearby villages. programmes seek to reduce the intensity of
infection to a level where symptoms are
REDUCING THE MICROFILARIAL DENSITY Ivermec- absent. The criteria used in the Onchocer-
tin immobilizes microfilariae, which are ciasis Control Project (OCP) in West Africa
flushed out of the skin and eye and killed were:
in the lymph nodes. As microfilarial
death occurs away from the skin and eye, . less than 100 infective larvae/person/
irritation is minimized and ocular reaction year;
reduced. It can be given as a single dose . annual biting rates of less than 1000.
of ivermectin 200 mcg/kg with re-treat-
ment at 6- and 18-month intervals. This After many years of operation, the OCP pro-
means that mass therapy for onchocerciasis gramme finished in 2002, with delegation to
can be used as an adjunct to vector individual countries to detect and treat all
control. new cases.
The main method of control is larvicid-
REDUCING THE NUMBER OF ADULT WORMS Since ing, which can be extremely effective if
the adult worms live for a considerable carried out thoroughly. Species eradication
period of time, during all of which they are of S. naevi was achieved in Kenya by
producing microfilariae, specific attack on methodically treating every water course
the adult parasites can reduce both with DDT. Where the disease covers a
the symptoms and potential for transmitting limited area, such an intense programme
infection. Nodulectomy or the surgical could be considered. In a more diffuse
removal of adult worms from skin nodules focus, the borders of control need to be
can be a relatively effective procedure, extended sufficiently to prevent re-invasion
practised particularly in the Guatemala by Simulium flying in from outside. While
onchocercal areas where nodules, more resistance is a serious problem, resistant
common in the upper parts of the body, Simulium are less important in transmis-
are likely to produce ocular lesions. Moxi- sion.
dectin, used in veterinary medicine, Mass drug therapy, or selective treat-
has been found to kill adult worms, so is ment to persons with heavy infections,
likely to be used in the treatment of the can be given right from the start of the
individual and community if free of side- programme. This will rapidly reduce the
effects. microfilariae level and the potential for
infecting flies. Preventing blindness (with
ivermectin) has been particularly valuable
REDUCING THE NUMBER OF SIMULIUM BITES Per-
in obtaining the cooperation of people. As
sonal protection is less effective against
lymphatic filariasis and onchocerciasis
Simulium than with mosquitoes, with nets
occur in the same areas in a number of coun-
being inappropriate, although repellents
tries (mainly in West Africa) and ivermectin
have some effect. The wearing of long-
is used to treat both diseases, joint pro-
sleeved shirts and long trousers with a hat
grammes (with the addition of albendazole)
and net can be used by individuals investi-
are cost-effective. Moxidectin, which
gating the disease, but are not methods that
remains in the plasma for a much longer
can be developed for mass use. Avoiding
period (20 days as opposed to ivermectins
passage through breeding sites will reduce
2 days), could permit more flexible treat-
fly biting.
ment regimes.
ONCHOCERCIASIS CONTROL PROGRAMMES Adult Treatment Ivermectin has been very effect-
O. volvulus can live for 1517 years, so any ive, especially in the reduction of blindness,
control programme would need to be main- but moxidectin with its killing effect on
234 Chapter 15
adult worms may produce a more radical Occurrence and distribution Loiasis is found
cure. in the West and Central African rain forests,
especially the Congo River basin.
Surveillance Skin and nodule surveys can be
used to indicate areas that need more in- Treatment Both adults and microfilariae are
tense skin-snip examination (see also the killed by DEC, but caution needs to be exer-
OCP programme above). cised as allergic reactions can be profound.
Low dosages of 0.1 mg/kg can be used to
initiate treatment, gradually building up
15.9 Loiasis over 8 days to 6 mg/kg, which is continued
for 3 weeks. Steroid cover may be required
Organism Loa loa, a nematode worm. The in those with more than 30 microfilariae/
life cycle of the parasite is essentially the mm3. Ivermectin will reduce the microfilar-
same as W. bancrofti, except that the vectors ial stage and produces less reaction, so is
are Tabanid flies. more suitable for mass control programmes.
However, reactions do still occur, especially
Clinical features The disease is character- in those in whom the worm is seen crossing
ized by Calabar swellings (named after a the eye. So a useful preliminary examin-
town in Eastern Nigeria), which are transi- ation is to show people a picture of the
ent, itchy and found anywhere on the body. worm in the lower eye and exclude those
Fever and eosinophilia suggest they have an in which it has been seen.
allergic aetiology. L. loa is often confusingly
called the eye worm (to be differentiated Control and prevention Extensive control
from O. volvulus), as the worm is sometimes measures are generally not warranted, the
seen migrating across the conjunctiva, but main preventive action being against
produces no pathology in the eye. the bites of Chrysops with protective
clothing and repellents. Clearing the forest
Diagnosis L. loa is diurnally periodic and canopy, oiling of pools and mass treat-
diagnosis is made by examining daytime ment (with ivermectin) are methods that
blood in which the microfilaria (Fig. 15.9) have been practised in areas of high trans-
will be found. Mansonella ozzardi, M. permission.
stans and M. streptocerca are also com-
monly found in blood and skin smears in Surveillance Surveys for Calabar swellings
the same area and need to be differentiated or a history of them will indicate the area
from L. loa as well as W. bancrofti and O. in which to take a blood smear survey.
volvulus.
Transmission The vector is Chrysops, a large, 15.10 African Trypanosomiasis (Sleeping

powerful fly which inflicts a painful bite, Sickness)
attacking either within the forest or forest
fringe. Organism There are two forms of human
sleeping sickness in Africa one due to
Incubation period Although microfilariae Trypanosoma brucei gambiense and the
may appear in the blood after about other caused by T. b. rhodesiense. A third
6 months, the first symptoms may take years. form T. b. brucei is found in cattle, causing
considerable economic loss.
Period of communicability Like O. volvulus, The trypanosome exists in several dif-
the adult can live for up to 17 years, produ- ferent forms during its life cycle (Fig. 15.18).
cing microfilariae all this time. L. loa takes When seen in human blood, the trypomasti-
1012 days to produce infective larvae in the gotes are long and slender, short and
fly. stumpy, or intermediate between the two,
probably representing a cycle of antigenic opmental stage. However, as the infective

variation (Fig. 15.18). They are introduced form for the fly and the human is the same
into the blood by the bite of the tsetse fly and (trypomastigote), mechanical transfer can
multiply locally. After being disseminated occasionally happen if a contaminated fly
round the body, they continue to multiply, bites another person within a short space of
rapidly in T. b. rhodesiense, less so in T. b. time.
gambiense. They are infective to any tsetse The tsetse fly (Glossina) is easily recog-
fly when the fly bites, being taken up into nized by its characteristic stance and behav-
the mid-gut. They multiply, migrate into the iour. It is a large, powerful fly and rests on a
space between the peritrophic membrane surface with wings folded like a pair of scis-
and the gut wall and pass forward to the sors. Within the venation of these wings, a
salivary glands. The epimastigote develop- characteristic hatchet cell (Fig. 15.14) can be
mental form changes into a trypomastigote defined which helps in identification. How-
to infect the next person who is bitten. ever, when passing through fly country,
there is normally no doubt about its pres-
Clinical features The bite of a tsetse fly gen- ence, as tsetse flies attack any moving object
erally causes a local reaction, but 710 days in large numbers, rendering the most painful
after it has subsided, it can become red bite. They are attracted by movement and
and inflamed, which is the first sign of will cling to the side of a vehicle travelling
infection. Trypanosomes multiply at the at 3040 km/h without being dislodged.
bite site and aspirated fluid will contain They prefer dark colours and if there is a
the dividing forms. In T. b. gambiense, an large object, they will fly to that in prefer-
enlargement of the lymph glands takes ence. They are more abundant near their
place, especially those in the cervical preferred breeding place in the sandy soil
region. This rarely occurs in T. b. rhode- beside rivers.
siense, the disease progressing rapidly to Distribution of tsetse flies is shown in
involve the CNS, with invariably a fatal out- Fig. 15.15, where it will be noticed that dis-
come. The main clinical signs are fever and tinct species are often related to particular
protracted headaches. In T. b. gambiense, sleeping sickness areas (compare with Fig.
the course is much more prolonged and per- 15.16). Table 15.5 is a simplified guide for
sonality changes may be the indication of assistance in identifying the species of Glos-
infection, but inevitably the disease leads sina, but professional confirmation should
to progressive lethargy, emaciation, coma always be obtained.
and death.
Incubation period 3 days to 3 weeks in T. b.
Diagnosis is by finding trypomastigotes in rhodesiense, months to years for T. b. gam-
the blood, CSF or gland puncture. The biense.
blood smear should be repeated several
times before a negative diagnosis is made. Period of communicability The trypanosome
Parasite concentration techniques, such as takes 1230 days to complete its develop-
capillary tube centrifugation or minianion mental stage in the tsetse fly, and depending
exchange centrifugation, are valuable. Anti- on temperature, the fly then remains
bodies may be detected by serological tech- infected for life. Humans can be infected
niques, while circulating antigen using the for many years with T. b. gambiense, but
Card Agglutination Test (CATT) in which a due to the shorter history with T. b. rhode-
drop of finger prick blood is mixed with siense, the animal reservoir is probably more
a suspension of trypanosomes has revolu- important.
tionized diagnosis. This technique is par-
ticularly useful for surveys in the field. Occurrence and distribution T. b. gambiense
mostly occurs to the west of the Central
Transmission is from the bite of the tsetse fly Rift Valley of Africa, containing the lakes
in which the parasite goes through a devel- of Tanganyika, Kivu, Edward and Albert,
236 Chapter 15
Puparium
T. gambiense
(no animal reservoir) T. rhodesiense
Adult (animal reservoir)
Hatchet
cell
T. brucei
(nagana)
Fig. 15.14. African trypanosomiasis.
while T. b. rhodesiense is to the east (Fig. Humans are the main reservoir of T. b.
15.16). T. b. gambiense infection is particu- gambiense infection (although the domestic
larly prevalent in Congo (formerly Zaire) pig may be involved) and people whose jobs
and T. b. rhodesiense in Tanzania. These brings them into contact with the infected
two diseases differ markedly in their epi- fly are more likely to succumb to infection.
demiology and control. Since women are involved in the collection
of water for domestic use, the preparation of
food and the washing of clothes, they are
more commonly infected with Gambian
15.10.1 Gambian sleeping sickness sleeping sickness.
The disease can occur in both endemic
Sleeping sickness as with other vector-borne and epidemic forms. There are well-known
diseases is determined by the habits of the foci from which people become infected at a
vector. In the gambiense type, the tsetse fly constant rate (Fig. 15.16), but movements of
breeds in the tunnel of the forest, along the infected flies or more commonly people,
course of rivers (Fig. 15.17). Although into new areas can initiate epidemics. Gen-
powerful flyers, they do not range far from erally, infected flies are comparatively few
this shaded protection, but travel exten- in number, so that a large number of bites are
sively through this tunnel of forest in search required before a person becomes infected.
of blood meals. Any mammals, including Where the community that is fed upon is
humans, that come to the river to drink or small and stable (less than ten persons/
cross are attacked and fed upon. km2), only a few cases will occur. When
Fig. 15.15. Tsetse fly distribution in Africa: , Glossina morsitans; \\\\\, G. pallidipes; jjjjj, G. palpalis
and G. fuscipes; /////, G. tachinoides.
the community is much larger (above ten and Julbemardi spp.), is found in large areas
persons/km2), as when an infected person of East Africa. Smaller wild animals inhabit
travels to a more densely populated area, it, especially the bushbuck that forms a res-
the infection can be transmitted to other ervoir of infection. Towards the margins of
people, who in turn form a reservoir to infect this forest belt, it breaks up into thickets
more flies and an increasing number of cases separated by savannah grassland in which
occur. Epidemic sleeping sickness is more large numbers of wild animals are found.
likely in T. b. gambiense infection, as it is a The tsetse fly ranges widely over these
more chronic disease and cases provide a areas, feeding mainly on animals and using
reservoir (to infect flies), before symptoms the thickets for cover and shade. It is, there-
cause them to seek medical attention. While fore, humans who travel through the forest
endemic foci are difficult to eradicate, con- fringing savannah in their occupational pur-
trol measures should prevent epidemics suit and the hunter and honey collector
from occurring. who become infected. Adult males are then
the main victims in rhodesiense sleeping
sickness.
15.10.2 Rhodesiense sleeping sickness T. b. rhodesiense infection is not a focal
disease and because of its short clinical
The principal vector of T. b. rhodesiense is course, epidemics are uncommon. However,
G. morsitans, which breeds along water movements of people, such as the develop-
courses, but then travels widely throughout ment of new settlements in forest areas, will
the extensive shade cover provided by the expose a large number of people to infected
forest belt. This open type of forest, com- flies all at the same time, so allowing an
monly called miombo (mainly Brachystegia epidemic to start. The first signs that this is
238 Chapter 15
Fig. 15.16. Sleeping sickness foci in Africa. T. b. gambiense; T. b. rhodesiense.
happening are where women, and espe- crossing, water collection place or inhabited
cially children, become infected. area.
Although these are the main patterns of In East Africa, where extensive forest
the two diseases, sometimes a riverine tsetse provides a habitat for the fly, the forest
fly becomes the vector of rhodesiense sleep- margin is pushed back from any place
ing sickness. of habitation. A band of at least 1 km,
preferably 2 km, should be left between the
Control and prevention area of habitation and the forest. This must
also include any cultivated area and regula-
VECTOR CONTROL. Knowledge of the habits tions are required to prevent people from
and behaviour of the local vector is neces- moving into the cleared part to start new
sary before embarking on methods of vector cultivation. Ring barking is a more econom-
control. The principal method is to modify ical method of forest clearance than cutting
the environment so that it is unsuitable down every tree.
for the fly, but not to cause so much damage Where forest clearance is impractical,
that the water table is affected or soil erosion insecticides can be used. This is easiest
results. With the riverine type of habitat, along the course of substantial rivers using
areas of the forest tunnel are cleared remov- a boat, spraying the forest on either side. In
ing all the dense undergrowth, but leaving the savannah-type habitat, isolated thickets
the big trees with their extensive root can be treated. Extensive insecticidal appli-
systems to prevent erosion of the river cation to miombo forest is inappropriate.
bank (Fig. 15.17). Clearance should be con- Insecticides have to be repeatedly used,
tinued for 0.5 km on either side of a river whereas forest clearance is permanent and
Table 15.5. A simplified key to Glossina of medical importance and their favoured habitats.
Hind tarsi All segments dark above G. palpalis group (1)

Only two distal segments dark above G. morsitans group (2)
1. Abdomen obviously banded dorsally G. tachinoides
Abdomen dark, unbanded dorsally G. palpalis (W. Africa)
G. fuscipes (E. Africa)
2. Distal two segments of front and middle tarsi without G. pallidipes
dark tip
Last two segments of front and middle tarsi with dark tip (3)
3. Bands of abdomen very distinct and sharply rectangular G. swynnertoni
Bands on abdomen rounded medially and less distinct G. morsitans
In summary, the vectors of T. b. gambiense are
G. palpalis
G. tachinoides
G. morsitans
and of T. b. rhodesiense
G. morsitans
G. pallidipes
G. fuscipes
G. swynnertoni
G. tachinoides in SW
Ethiopia
Favoured habitats are:
a. Lake and riverside, fringing forest G. palpalis
G. tachinoides
G. fuscipes near Lake
Victoria
b. Fringing forest without permanent water G. pallidipes
c. Miombo woodland, thickets and game savannah woodland G. morsitans
d. Restricted to northern Tanzania game savannah woodland G. swynnertoni
the relative costs of these two techniques people away from the sleeping sickness
needs to be considered. areas is the ultimate method of control, but
Trapping can also control the vector. one to be taken only when all else fails.
A well-designed trap will collect enough The preferable alternative to moving
flies to considerably reduce the biting risk. populations is to modify the habitat so that
An effective trap has a fine metal mesh it is unsuitable for transmission. Methods of
treated with insecticides, which is shaded forest clearance have already been des-
to attract tsetse flies. These are rapidly cribed, while providing water supplies will
killed when they touch the screen, but remove the reliance on obtaining water from
this must be cleaned regularly to work rivers.
efficiently. The density of population largely
The fly can bite through thin clothing, determines the endemicity, as mentioned
so taking preventive action from being bitten above. Two different approaches can be
in a tropical climate is difficult. taken:
ALTERATION OF THE HUMAN HABITAT Sleeping . keep the population close together and
sickness has been responsible for large clear an area of forest around them;
movements of people from their traditional . encourage the people to spread out very
homelands, either by choice or by govern- widely so that they partially clear a large
ment action to avoid an epidemic. Moving area of forest.
240 Chapter 15
Fig. 15.17. Tunnel of forest along the banks of a river with selective clearance (leaving the big trees).
In the first method, the people are safe as from this alternative source, then game can
long as they remain within the village, but be killed or driven off.
once they pass through the forest, they are
subjected to a considerable number of bites. Treatment of cases requires hospitalization
In the second alternative, people will as the drugs are highly toxic. Suramin is
become infected in the initial stages of forest effective in early and intermediate cases of
clearance, but once this has been done, then both T. b. rhodesiense and T. b. gambiense.
protection will be much greater and more When the CNS is involved, Melarsoprol
use can be made of the land. In the initial is the drug of choice. Eflornithine is very
period of forest clearance, a surveillance ser- effective in all stages of T. b. gambiense
vice will be required to find these pioneer infection (including cerebral), but is not
cases. The most unsatisfactory solution is a effective in T. b. rhodesiense. Pentamidine
moderately large population spread evenly has been used as a prophylactic against T. b.
over the area; this is the potential situation gambiense to people at special risk. There is
for an epidemic. no prophylactic against T. b. rhodesiense
infection.
PARASITE REDUCTION A surveillance service
should be set-up and all cases treated (see Surveillance In a sleeping sickness area,
below). Finding cases in the early stages a surveillance service should be set up.
of the disease, not only increases the chance Sleeping sickness workers are recruited
of successful treatment, but also removes a more on their knowledge of the local com-
potential source of infection to tsetse flies. munity than their medical skills, as the
Another approach to reducing the para- simple techniques of gland puncture or
site reservoir in T. b. rhodesiense is to des- making a blood slide can easily be taught.
troy the animal population. This used to be The workers cover a set area and take slides
practised on a wide scale, but animal conser- from people with symptoms of persistent
vation has now questioned the wanton fever and headache, or those who pursue a
slaughter of animals. In most cases, it will particular occupation, such as hunters,
be found that the human reservoir is more honey collectors or wood-cutters. In T. b.
important than the animal, but where there gambiense infection, palpation for neck
is evidence that flies are becoming infected glands can provide a useful estimate of
prevalence. In an epidemic of T. b. rhode- Transmission is by Reduviidae bugs,

siense, a mass blood slide examination can differing from area to area according to the
be performed in the worst-affected areas to species of the Reduviidae and the reservoirs
detect asymptomatic cases. of infection. The main genera of bugs are
The illness in animals is more extensive Triatoma, Rodnius and Panstrongylus,
than in the human population and which can be differentiated from each
veterinary services often set-up extensive other by their antennae and mouth parts
surveillance and control programmes, so (Fig. 15.19). Essentially, there are two
combining efforts with them can be of value. cycles, one wild and the other domestic,
which are illustrated in Fig. 15.20.
In the wild cycle, armadillos, opossum,
15.11 American Trypanosomiasis raccoons and a number of other animals
(Chagas Disease) have been found infected, living in close
proximity to their burrow-inhabiting bugs.
Organism Trypanosoma cruzi. The trypano- This infection remains as a zoonosis until
some in American trypanosomiasis under- disturbed by a domestic animal, commonly
goes a development cycle both in the vector a dog ferreting around the burrows of these
bug and the vertebrate host, with wild animals. They are attacked by the bugs
trypomastigotes, the infective form and and acquire the infection. On returning to
pseudocysts forming in the muscle. These the house, the dog becomes a reservoir for
contain amastigotes, which grow a flagellum the domestic bugs, which transmit the infec-
to become promastigotes and epimastigotes tion to any humans living or staying in the
(Fig. 15.18) when the pseudocyst ruptures, house.
finally developing into infective trypomas- In Central America, the cycle is semi-
tigotes (Fig. 15.19). The trypomastigote of domestic with the reservoir maintained in
the American disease has a larger kineto- the domestic rat (Rattus rattus), from
plast and is more curved than the African which house-haunting bugs pass on the in-
one. The infection differs in that repeat fection to people in the house. Although the
cycles take place in the hosts muscles pro- bugs feed on people, it is the passage of
ducing a chronic disease state. trypanosomes in the bug faeces, which are
rubbed into the wound or conjunctiva that
Clinical features American trypanosomiasis produces the infection.
presents as an acute infection, generally in The bugs live in cracks in the walls and
children, with fever, local swelling at the floors and within the thatch in the roof. The
site of inoculation and enlargement of the mud and wattle type of structure is particu-
regional lymph nodes. Muscular tissues are larly suited to the conditions required. The
attacked so that in adult life, chronic condi- number of bugs hiding within the cracks and
tions such as enlargement of the heart, oe- crevices can be several hundreds.
sophagus or colon develop. Heart failure Infection can also be transmitted by
and cardiac irregularities are common mani- blood transfusion, and small epidemics in
festations that lead in the course of time to a group of people sharing the same food
disability and early death. In HIV infection, suggests that contamination of food by bug
acute myocarditis or meningoencephalitis faeces could lead to transmission by the oral
can occur. route.
Diagnosis is by finding the organism in the Incubation period 514 days.

blood in the acute stage. Methods of concen-
trating the erythrocytes or xenodiagnosis Period of communicability Bugs become
(feeding of laboratory-reared clean bugs on infected after 810 days and remain so for
the patient) are often required. In the life, which lasts about 2 years. Infected per-
chronic case, serological tests may be posi- sons have circulating trypanosomes in the
tive. acute and early chronic stages of the disease,
242 Chapter 15
Nucleus
Kinetoplast
Amastigote
Promastigote Epimastigote
Pleomorphic
forms
Long slender form
Short stumpy form
Trypomastigote
Fig. 15.18. Different forms of the trypanosomidae.
and this may persist in small numbers for Control and prevention The methods of con-
the life of the individual. trol are to reduce the number of bugs that
can come into close proximity with humans
Occurrence and distribution Chagas disease and the reservoirs of disease. These require-
is found throughout Central America and in ments are both satisfied by improvements to
most countries of South America. Consider- housing. Unfortunately, trypanosomiasis is
able progress has been made in controlling a disease of poverty, and building new and
the disease, Uruguay being declared free of better houses is rather impractical in this
infection in 1997, Chile in 1999 and Brazil in segment of the population. If assistance can
2000. Argentina and Venezuela will prob- be given, then proper foundations and
ably be declared free very soon. cement walls will not only deny a place for
Panstrongylus
Triatoma
Reduviid bug
Rhodnius
Trypomastigotes ingested Trypomastigotes deposited

in blood meal Multiplication in midgut in bug faeces
Vertebrate cycle
Rupturing Trypomastigotes
pseudocyst Pseudocyst enter muscle cells
Fig. 15.19. Life cycle and vectors of American trypanosomiasis (Chagas disease).
the bugs to live, but also prevent rats and The use of pyrethroid fumigant cans
armadillos from making their burrows which release insecticide when lit, and
underneath them. Even with existing insecticidal paints are simpler methods
houses, much can be done by applying a than residual spraying.
layer of mud plaster to walls and erecting a An alternative is to protect the individ-
simple ceiling. Where cost prohibits any of ual from being bitten by the use of ITMN
these methods, residual insecticides can be (see further under malaria discussed previ-
sprayed on the walls and ceilings. This can ously).
effectively be carried out as a control pro- The dog is probably the most important
gramme using a similar methodology to mal- domestic reservoir and householders should
aria. question the value of maintaining such
First a pyrethrum spray is administered, animals if they are proving a threat to the
which draws the bugs out of their hiding health of the family. Good hygiene, trapping
places and marks the infected houses. In and poison will keep down rats. Control of
the attack phase, a residual insecticide the wild reservoir is unlikely to be successful.
is sprayed on all houses in an infected In areas of high endemicity, screening
locality (not just to infested houses). of blood donors is required and gentian
A second spraying is made 90 days after violet can be added to the blood.
the first, to houses where bugs have been
found either in the preliminary or attack Treatment Nifurtimox and benznidazole are
phase. Spraying continues at this time inter- effective in the acute and early chronic
val until the number of infested houses phase of the disease.
falls below 5%. Maintenance is achieved
by regular house searches, instituting Surveillance Regular monitoring of houses
focal spraying when re-infestation is dis- for signs of infestation or re-infestation
covered. should be maintained (see above).
244 Chapter 15
Semi-domestic
cycle
Domestic cycle
Wild cycle
Fig. 15.20. Transmission cycles of American trypanosomiasis.
15.12 Leishmaniasis They are all transmitted by the bite of

the sandfly and undergo the same simple
Organism. There are seven species of Leish- life cycle. Promastigotes enter man with
mania and a number of subspecies: the bite of the sandfly, change into amasti-
gotes (Fig. 15.18), and are engulfed by
macrophages. They multiply and finally
Visceral L. donovani rupture the cell, invading other macro-
leishmaniasis (donovani, infantum, phages. When the sandfly takes a blood
chagasi, meal, they change into promastigotes.
archibaldi)
These multiply continuously so that the
Mucocutaneous L. braziliensis (braziliensis,
peruviana), L.
number produced can be so large as to
guyanensis block the fore-gut. When the insect next
(guyanensis, bites, it is forced to regurgitate promasti-
panamensis) gotes into the host before it can take a blood
New world L. mexicana (mexicana, meal (Fig. 15.21).
cutaneous amazonensis, pifanoi, In cutaneous leishmaniasis, the amasti-
garnhami, gotes remain at the site of introduction, con-
venezuelensis) tained by the macrophages of the skin. In
Old world cutaneous L. major visceral leishmaniasis, large mononuclear
Old world cutaneous L. tropica (killicki,
cells and polymorphonuclear leucocytes
tropica)
Old world cutaneous L. aethiopica
become invaded, which subsequently carry
the parasites to the viscera, especially
Promastigotes injected Amastigotes ingested by sandfly
Mammalian host
Amastigotes rupture
macrophages and invade
others
Visceral Mucocutaneous New World cutaneous Old World

L. donovani L. braziliensis L. mexicana L. major
L. guyanensis L. tropica
L. aethiopica
Fig. 15.21. Leishmania vector, parasite and life cycle.
the liver, spleen and bone marrow. The kala-azar dermal leishmaniasis can occur
mucocutaneous form is intermediate, the after apparent cure of the visceral case.
parasite restricting its attack to the reticulo- Like leprosy, host response largely de-
endothelial system of the mucus membranes termines the outcome of the disease and in
of the mouth, nose and throat. any condition in which this response is min-
imized a more florid disease results.
Clinical features There are three main clin- Cutaneous leishmaniasis is normally a self-
ical forms of the disease cutaneous, muco- limiting condition, but in some individuals
cutaneous and visceral (kala-azar). The diffuse cutaneous leishmaniasis, in which
cutaneous infection starts with a papule metastatic lesions are disseminated around
and enlarges to become an indolent ulcer, the body can occur. The resulting nodular
which either heals or persists for many lesions resemble lepromatous leprosy and
years. In the New World infections, a more respond poorly to treatment. So any condi-
aggressive form of mucocutaneous leish- tion that compromises the host response,
maniasis (espundia, Chiclero ulcer) results such as HIV infection, may lead to reactiva-
in nasopharyngeal destruction and hideous tion of latent disease or cutaneous disease
deformities. The visceral form is a chronic progress to visceral illness. Leishmaniasis,
infection with fever, hepato-splenomegaly, like tuberculosis, is intertwined with HIV
lymphadenopathy and anaemia. There is infection so that in areas where leishmania-
progressive emaciation and weakness with sis is found, both conditions have a more
generally a fatal outcome if not treated. Post- serious outcome.
246 Chapter 15
Diagnosis is by the detection of the develop in the ground during the dry
intracellular-infected macrophages (Leish- season.
manDonovan bodies) in liver, spleen, The life cycle from oviposition to emer-
bone marrow or cutaneous lesions by gence of the adult can take 30100 days
stained smear or culture. PCR techniques depending on species and temperature,
can also be used. while the adult lives for approximately
2 weeks. Only the female sucks blood, but
Transmission is by the minute and fragile lizards, birds and mammals are satisfactory
phlebotomine sandflies, Phlebotomus and alternative food sources to humans.
Lutzomyia. They are weak fliers, utilizing Most species feed out of doors during
a hopping flight that only carries them a the evening and night, or in the day when
short distance from their habitat. This re- there is shade or the weather is overcast.
quires conditions of high humidity as If it is windy, they are unable to fly. They
found in animal burrows and moist tropical are not able to bite through clothing and
forests. Typical habitats are tree holes, new mainly attack the lower parts of the
or old animal burrows, termite hills, rock body. The main vectors are summarized in
crevices, foliage clumps and fissures that Table 15.6.
Table 15.6. The vectors and reservoirs of leishmaniasis.
Type and
parasite Geographical area Main vector Reservoir
Visceral
L. donovani Mediterranean, SW Asia Phlebotamus peniciosus, P. Dogs, foxes
(including infantile) ariasi, P. major syriacus, P.
longicuspis
Central Asia P. major syriacus, P. smirnovi, Dogs, jackals, foxes
P. longiductus
China P. chinensis Dogs
India, Bangladesh P. argentipes, P. papatasi Humans
Sudan, Chad P. orientalis, P. martini Wild rodents and
carnivores
Kenya P. martini Dogs
Central and South America Lutzomyia longipalpis Dogs, foxes
Mucocutaneous
L. braziliensis Central and South America L. wellcomi, L. umbratilis, Rodents and forest animals
L. guyanensis L.trapidoi
Cutaneous (New World)

L. mexicana Mexico, Belize, Guatemala L. olmeca Forest rodents
Amazon Basin L. flaviscutellata Forest rodents
Peru L. peruensis, L. verrucarum Dogs
Cutaneous (Old World)

L. major Mediterranean P. papatasi Rodents, dogs, gerbils
Southwest Asia P. papatasi, P. sergenti Dogs, rodents
L. tropica Central Asia P. papatasi Rodents, gerbils
India P. sergenti Dogs
West Africa P. duboscqi Dogs, rodents
L. aethiopica Ethiopia P. longpipes Hyrax
Kenya P. pedifer Rodents
, visceral.
, Cutaneous;
Fig. 15.22. The global distribution of cutaneous and visceral leishmaniasis.
248 Chapter 15
A range of reservoirs is found in this the other species of Leishmania, but an

complex of diseases. In Central Asia, cuta- attack of kala-azar will protect against de-
neous leishmaniasis is a zoonosis, the gerbil veloping kala-azar in any other part of the
being the main reservoir. In India, there is a world.
domestic reservoir, mainly dogs, but direct
human-to-human transmission also occurs. Control and prevention Cases of the disease
These are summarized in Table 15.6. are normally sporadic, so should be treated
Transmission can also take place dir- to prevent flies from becoming infected. Re-
ectly through needles and other instruments pellents and personal protection adequately
contaminated with blood of an infected protect the individual from being bitten.
person. Sadly, this is also the method by Sandfly nets can be used, but a more effect-
which HIV is transmitted in many develop- ive solution is ITMN or LLIN (see Malaria
ing countries. above). Because of the fragile nature of the
vector, it is easily attacked with insecticides,
Incubation period 2 weeks to 6 months, but either with a residual house spray if the
can be years. vector comes indoors, or by insecticide
powder blown into mammal burrows, ant
Period of communicability The untreated hills and similar micro-habitats. A long-
case can remain infectious to sandflies for term solution is to alter the micro-environ-
up to 2 years. ment, such as by the destruction of termite
hills and killing of rodents. Proper control of
domestic animals, especially dogs, can be
Occurrence and distribution Leishmaniasis
effective where they are important reser-
is found in Central and South America,
voirs. Low-dose inocula and attenuated vac-
north of the equator in Africa , in the Medi-
cines have been developed to minimize the
terranean, Southwest, Central and South
severity of disease in some endemic areas.
Asia and part of China as shown in Fig.
The concomitant problem of HIV infection
15.22 and Table 15.6. Population move-
has added to the seriousness of dual infec-
ments, both of persons from endemic rural
tion, so a simultaneous programme of STI
areas into towns and large man-made pro-
control is required and information pro-
jects, such as dams in endemic foci, have
duced on how to avoid both diseases.
brought an increasing number of people
into contact with leishmaniasis. Also, the
spread of HIV infection has made what was Treatment is with sodium stibogluconate or
largely a curable condition into a persistent meglumine antimonate, but pentamidine or
source of parasites for the vector sandfly and amphotericin B may be required in cases
as a result, a more serious disease. that do not respond, especially mucocuta-
Immunity develops following infection neous leishmaniasis. Because of the toxicity
with the parasite, but there is little cross- of the preparations, treatment should be
immunity. L. tropica has been used for undertaken in hospital. Miltefosine maybe
a long time as an inoculum to induce a useful in the treatment of visceral leishman-
sore on a hidden part of the body so as iasis.
to prevent a more disfiguring lesion de-
veloping on the face. L. major will protect Surveillance Outbreaks should be reported
against L. tropica as well as L. major to neighbouring countries so that they can
lesions, and suspensions of living organisms take control measures in border areas. Pa-
have been prepared for this purpose. There tients with HIV infection should be exam-
is no cross-immunity with kala-azar and ined for reactivated leishmaniasis.
16
Ectoparasite Zoonoses
Ectoparasites are non-flying vectors of dis- Clinical features The disease in humans, due
ease, such as fleas and lice. They are respon- to the bite of an infected flea, is called bu-
sible for an important group of infections, bonic plague, after the bubo or swelling that
which are often associated with animals in develops at the regional lymph nodes
which the reservoir of infection is found. draining the site of inoculation. It is com-
Because of the close inter-relation between monest in the groin and secondly in the
the ectoparasite and the animals on which axilla, while it can also occur in the cervical
it feeds, focal zoonoses (or exoanthropic lymph nodes. This latter site is more likely
zoonoses) result. Humans are often the in the case of sylvatic plague as infection can
accidental victims of these zoonotic infec- result from ingesting the organism when
tions, and a knowledge of the biology and eating the reservoir rodent. (Some people
how to avoid these foci can often be all eat rodents as a normal item in the diet,
that is needed to prevent being infected. while in famine conditions, others may be
At other times, specific methods against driven to eat whatever they can find, includ-
the ectoparasite, the animal or both are ing rats.)
required. The bubo is painful and tender,
becomes fluctuant and often breaks down
to discharge pus. There is an associated
high fever, confusion, irritability and signs
16.1 Plague of haemorrhage may develop. These may be
subcutaneous, into the stomach or intes-
Organism Yersinia pestis, the fragile tines, leading to prostration and shock with
organism that causes plague is a small oval- death soon after.
shaped bacillus that stains negative with In a few cases, the disease may be over-
Grams stain. It is sensitive to heat above whelming from the start with septicaemic
558C, 0.5% phenol for 15 min and exposure plague. All the signs are more severe and
to sunlight. Y. pestis occurs in three var- develop so rapidly that a bubo is not formed
ieties, orientalis, antigua and mediaevalis, and the patient is dead within a few days. In
separated by their ability to ferment glycerol the generalized spread of the organism
and reduce nitrates, which can be useful around the body, it can invade the lungs
in elucidating the particular organism in- and should a case of bubonic or septicaemic
volved in an epidemic. plague start coughing out bacteria, then
249
250 Chapter 16
transmission can occur via the respiratory are similar to wars of man and a replacement
route. This leads to pneumonic plague, of one group of plague-resistant rodents by
where spread is from person-to-person con- another of no resistance could cause a
tact and the flea is not involved. It is highly change in the ecological balance. On the
infectious and lethal, so stringent protective other hand, an increase in the domestic
action must be taken. About 5% of bubonic rodent population may expand into the
patients develop terminal pneumonia and wild rodent one. Whichever of these alterna-
transmit infection via the respiratory route. tive mechanisms takes place, the deprived
The onset of pneumonic plague is very quick flea seeks a new host and settles on a domes-
with shallow, rapid breathing, watery tic rodent. The domestic rodent being highly
blood-stained sputum, high temperature, susceptible to plague is rapidly killed,
pulmonary oedema and shock. Death occurs which brings the flea of the domestic rodent
between the third and the fifth day. in search of a new host and because of their
A mild form of the disease with swollen proximity, humans are likely to become the
glands and slight rise in temperature can next victims.
occur as pestis minor, but many cases go In Africa, the multi-mammate rat (Mast-
undiagnosed and tend to occur towards the omys natalensis) acts as an intermediary
latter part of an epidemic. During an epi- between the feral rodent reservoir and the
demic, routine throat swabs may detect domestic rat, feeding on the remnants of the
Y. pestis, but there is no good evidence that harvest. However, when the rains come, it is
transmission can occur from these cases. driven to look for alternative stores of food
and enters the home bringing it in contact
with the occupants. This makes a seasonal
Diagnosis Fresh aspirate from a gland or
pattern of plague. If there is a drought, the
sputum stained with Gram stain will show
situation is even more serious because there
the bipolar staining organism in preliminary
is no food for the desperate multi-mammate
field investigations. Culture on to blood agar
rat, which is forced early into conflict with
or desoxycholate can be made from blood,
the domestic rat and an epidemic occurs in
throat swabs, sputa and material aspirated
the dry season as well.
from buboes. Fluorescent antibody or anti-
A focus of plague is determined by three
gen-capture ELISA is a specific confirma-
factors: (i) the organism, (ii) the reservoir
tory test. Asymptomatic cases of plague are
host and (iii) the flea vector. Many fleas
common during epidemics and can be
have been incriminated as possible vectors,
detected near foci by the passive haemagglu-
but species of Xenopsylla are the most im-
tination test (PHA).
portant (X. cheopis, X. brasiliensis and X.
astia). In identifying fleas, they can either
Transmission Figure 16.1 illustrates the dif- have a comb on the top of the head or they
ferent transmission cycles of plague, the trio are combless. Xenopsylla is combless, differ-
of bacillus, rodent and flea, into which entiating it from Ctenocephalides, which is
humans can be fatally drawn. In the estab- the common dog and cat flea. The common
lished focus of wild rodent plague, infection human flea Pulex is also a combless flea, but
is maintained in a comparatively resistant lacks the other distinguishing feature of
colony of animals, which suffer little from Xenopsylla, i.e. the presence of a meral rod
the disease. If a person strays into this focus (these important features are illustrated in
as a hunter or trapper, then fleas from a wild Fig. 16.1).
rodent they have killed may bite them and Fleas are able to survive for consider-
cause plague. This is sylvatic plague and is able periods without taking a blood meal
generally an isolated case with little epi- (6 months) and the larval and pupal stages
demiological significance. The more import- are well adapted to changing conditions. If
ant event is when some change takes place there is a limited food supply or low tem-
in the wild rodent focus and domestic perature, then the larva may prolong this
rodents become involved. Wars of nature stage from 2 weeks to more than 200 days
Human
Wild Domestic
rat Pneumonic
rodent
plague
Domestic
Wild rodent
Flea Flea rodent Human
plague
plague
Bubonic plague
Human
Wild Domestic
rodent rat
Human
sylvatic plague Xenopsylla cheopis, the main vector of
human plague (note absence of comb
but meral rod on second leg)
page 251
Fig. 16.1. Plague vector and life cycles.
251
252 Chapter 16
and the pupae remain cocooned. When vi- people although infected individuals will
brations in the habitat, the emission of remain alive for only a few days.
carbon dioxide or a rise in humidity indicate
that an inhabitant has returned, the larva Occurrence and distribution Plague is a clas-
rapidly develops and the emergent flea sic example of an ectoparasite zoonosis, the
feeds on the new host. Fleas are not specific, greatest of all epidemic diseases. It has rav-
but prefer their normal host species and fer- aged the Orient, Asia and Europe, altering
tility may be reduced if they cannot feed on the course of history. Today it is confined to
them. Fleas rapidly abandon a dead host and established foci (Fig. 16.2) from which it
use their powerful hind legs to help them erupts from time to time, but fortunately
hop on to a new one. Once re-established, effective control now prevents the uncon-
they tend to crawl around and settle to a trollable pandemics of the past.
regular feeding pattern. If fleas take in Y. Plague is a disease of civil disturbance
pestis with their blood meal, these multiply and war. In recent history, the largest human
in the proventriculus and lead to a blockage focus has been in Vietnam. Persistent en-
of the feeding apparatus. When the flea tries demic foci in Madagascar and East Africa
to feed again, it regurgitates bacteria into the continue to produce cases, while a worrying
blood stream while trying to take up blood. It exacerbation was an outbreak of pneumonic
is unsuccessful, so moves to a new host and plague in Ecuador in 1998.
tries again. Blocked fleas are important in
rapidly infecting many people. Control and prevention The methods of con-
Over 340 species of mammals have been trol depend upon the transmission cycle in-
found susceptible to plague including volved (Fig. 16.1).
rabbits, monkeys, dogs, cats and camels, Wild rodent plague foci are often exten-
but the main reservoir is in rodents, particu- sive and harmless, and to try and destroy
larly rats. They differ in their susceptibility them a considerable task. If they are local-
so that a focus will die out where there is a ized and close to habitation, then it might be
highly susceptible colony, but persist where feasible to alter the environment by cultiva-
resistance is high. While it is the resistant tion or in a way that discourages rodents.
rodents that maintain a focus, it is the move- Precautions need to be taken that a plague
ment of susceptible animals, which is re- epidemic is not generated by such activity.
sponsible for extending plague. Where the Where hunters or soldiers have to pass
speed of mortality is high and the pool of through a plague focus, then personal pro-
susceptible animals limited, then the tection can be obtained from long trousers
exacerbation will collapse and the focus tucked into socks, treated with repellents or
return to its original boundary, but when a insecticides. Warnings should be given
coincidence of susceptible rodents abuts do- about the danger of touching or eating any
mestic rodents, then the stage is set for an animals killed.
epidemic in the human population. Foci of Domestic rodent plague depends upon
infection have been delineated (Fig. 16.2), the two components of the rat and the flea,
some of which have given rise to plague but the order in which they are attacked is
outbreaks, while others have all the poten- crucial according to the stage of the disease.
tial, but human disease has not occurred. To kill rats during a plague epidemic only
makes the infected fleas search for a human
host and increase spread. In the presence of
plague, the fleas must be controlled first.
Using insecticide powder (permethrin,
Period of communicability An unblocked bendiocarb, carbaryl or fenitrothione),
infected flea can remain alive for several burrows can be insufflated and rat runs lib-
months able to transmit infection. Pneu- erally dusted. Rats pick up insecticide on
monic plague is highly infectious and can their fur and take it into their nests with
spread rapidly within a concentration of them. Fleas do not like cleanliness and
page 253
Fig. 16.2. Known and probable foci of plague, 19591979. (Reproduced by permission, from WHO (1980) Weekly Epidemiological Record 32, p. 234. World Health
Organization, Geneva.)
253
254 Chapter 16
people should be encouraged to wash with pneumonic plague is highly infectious and,
soap and warm water. Clothes can be therefore, extreme precautions should be
searched and fleas picked off, but it is pref- taken. Gowns and full-face masks should
erable to boil clothing (see Box 16.1 for the be worn, while goggles are required to pro-
control of rats). tect the eyes as Y. pestis can be absorbed
Plague vaccine will protect persons at through the conjunctiva.
risk for several months, but should not be
relied upon. Chemoprophylaxis with tetra- Surveillance of foci should be maintained
cycline 250 mg four times a day or doxycy- with regular trapping of rodents to examine
cline 100 mg a day for a week should be them for infection and their flea popula-
given to close contacts of cases and medical tions. Notification of any confirmed or sus-
workers at risk. pected case of plague must be made to WHO
Quarantine of all cases is required by and neighbouring countries. Any person
international health regulations for a period travelling from an area where there have
of 6 days. All persons should be dusted with been cases of plague should be placed
insecticides to remove fleas and precautions under surveillance for 6 days.
taken to prevent aerosol spread from pneu-
monic cases. Any cases dying of plague
should be buried or burnt with aseptic pre- 16.2 Typhus
cautions.
There are many similarities between the
Treatment Effective treatment depends epidemiology of typhus and plague, and
upon the speed of making a diagnosis it is convenient to approach the disease in
and treating early. If plague has already the reverse order to which it is normally
been diagnosed in the area, then a confirma- described in order to assist in its descrip-
tory test should not be awaited. The clinical tion. While plague is a composite disease
presentation of fever and bubo in a severely of three different cycles utilizing the same
ill patient is sufficient and treatment organism and vector, there are three differ-
needs to be started immediately. This is ent forms of typhus (scrub, murine and epi-
either by: demic), each with its own organism and
vector (Fig. 16.3).
. Streptomycin 1 g followed by 0.5 g every Organism The causative organism of typhus
4 h, up to a total of 20 g; is a Rickettsia or Orientia, an intracellular
. Tetracycline 3 g immediately, followed by bacteria which requires cellular tissue of the
1 g three times a day for 12 days; host or ectoparasite to develop and repro-
. Doxycycline 100 mg every 12 h for duce. It can survive in the environment if
7 days; suitable conditions prevail (e.g. in louse
. Chloramphenicol 500 mg every 6 h for faeces); otherwise, it is sensitive to heat
710 days. (being killed by a temperature of 608C for
30 min) and easily by antiseptics.
Gentamicin and co-trimoxazole have also The typhus-producing organisms and
been used. their ectoparasites are as follows:
Streptomycin is the treatment of choice,
but can cause a Herxheimer reaction, so
tetracycline is preferable in the critically Scrub Orientia Trombiculid
ill. Resistant strains have occurred and typhus tsutsugamushi mites
the sensitivity of the organism should be Murine Rickettsia typhi Flea, X.
monitored. typhus (R. mooseri) cheopis
Epidemic
Isolation of cases is mandatory and the
typhus R. prowazekii Human louse
terminal bubonic case with pneumonia or
Ectoparasite Zoonoses 255
Clinical features Typhus was confused with indirect fluorescence antibody test, labelled
typhoid for a considerable period of time enzyme with ELISA, latex agglutination or
because they both produced fever, prostra- PCR can be used.
tion and a rash. Indeed, typhoid obtained its
name only when it was finally separated Transmission
from typhus as being a less infectious dis-
ease, with markedly abdominal symptoms SCRUB TYPHUS Like wild rodent plague,
and a milder rash. scrub typhus is a zoonosis in which humans
In the most severe form, epidemic are not involved. Well-defined areas, called
typhus, there is a sudden onset with head- mite islands, harbour rodents, mites and the
ache, pains, rigours and malaise as the tem- Orientia, which is transmitted between
perature rapidly rises to 408C or more; where them. A large number of rodents have been
it remains for the duration of the illness. incriminated, including rats, and it is their
The characteristic rash appears between system of burrows, runs and range of activity
the fourth and seventh day and consists that determines the limit of the mite island.
of petechial haemorrhages on the trunk and The rodents are fed upon by the larval stage
limbs, but sparing the face, palms and of various Leptotrombiculid mites that need
soles. As the disease progresses, the patient to take blood so that they can develop into a
becomes semi-stuporous with confusion, nymph and subsequently an adult. The larva
anxiety and considerable dullness. The pa- climbs up on to grass or vegetation and
tient appears unable to hear, talks nonsense awaits the passage of a rodent or any other
and has to be fed. By the third week, if treat- passing mammal to which it attaches itself.
ment has not been given, the patient will Once it has fed, it drops off and continues its
progressively recover or else sink further development in the soil. If during its feeding
into heart failure, bronchopneumonia and it sucks up O. tsutsugamushi, these develop
death. in the nymph and adult and are passed on
In scrub typhus, the illness similarly transovarially to infect the next generation
commences with fever, progressive prostra- of blood-sucking larvae. The mites appear
tion and a macular rash, but after a few unaffected by this infection, acting as a res-
days, the infective mite bite develops into ervoir, hardly requiring the mammalian host
an eschar. This is a red indurated area except to provide a blood meal for their own
with central vesicle that subsequently continuity. Such is the balance of this ar-
breaks down to leave a black scab. The rangement that a mite island can persist un-
severity of the disease varies markedly disturbed, causing harm to no one unless
from area to area, being a severe and fatal accidentally entered by humans. The larval
illness, similar to epidemic typhus in mite will attack people just as it will attack
some places, while in others, so mild and birds and other mammals that come crash-
innocuous that it passes as flu. I remember ing through its hunting ground, transmitting
visiting a school near a well-known mite the infection to its unusual host.
island, which expected all new students to Scrub typhus is the disease of the
have a minor illness for a day or two wandering farmer, hunter or travelling
and then be immune for the rest of their army, passing through or camping in
academic stay. mite islands. These can be very small and
In murine typhus, there is fever, localized or cover extensive areas, but gen-
followed by a rash, but the illness is milder erally, they are associated with transitional
than epidemic typhus, mortality is low and vegetation or fringe habitats, such as areas
complications rare so that most people fully separating different vegetation zones (e.g.
recover in 710 days. forest and grassland). Mite islands are
nearly always the result of human activity,
Diagnosis will probably be on clinical where forest is destroyed either for timber or
grounds, the escar of scrub typhus being in slash and burn agriculture. The land
characteristic, but where available, the regenerates as secondary growth, rats
256
Human
Rodent
Louse Louse
Flea
Flea
Rodent
Chapter 16
Rodent Human
Human
Epidemic
Murine typhus
typhus
Mite Recrudescent
Mite
typhus
Human
Leptotrombidium Human
Larva
Rodent Scrub typhus
page 256
Fig. 16.3. The transmission cycles and vectors of scrub, murine and epidemic typhus.
and other rodents move in and provide suit- where rats live in constant contact with
able conditions for the Leptotrombiculid humans.
mites.
EPIDEMIC TYPHUS While scrub typhus and
MURINE TYPHUS Scrub typhus has been murine typhus are zoonoses, epidemic typhus
given the alternative name of rural typhus, is an infection where only humans and the
which adequately distinguishes it from body louse, Pediculus humanus corporis,
urban typhus, the main characteristic of the are involved. The louse can spend its entire
flea-borne disease. Murine typhus is then a life cycle on the same host, laying its eggs in
disease of towns and habitation, maintained the seams of clothing and finding all the food
there by domestic rodents, Rattus rattus and and shelter it requires. Female lice lay some
R. norvegicus. In contrast to scrub typhus, 510 eggs per day, which hatch in 69 days
the mammal in murine typhus is the reser- depending on temperature. If the clothes are
voir of the disease and the common rat flea kept on the body, then the temperature
X. cheopis acts only as a transmitter. Many is maintained and hatching takes place rap-
other mammals have been found infected idly, but if they are removed and cooled down,
mice, cats, opossums, shrews and skunks development may take 23 weeks. One month
but the key in all these alternative sites is is the maximum period they can survive, so
always the domestic rat. clothes that are not worn for this length of time
The flea becomes infected by biting the will be free of lice.
host, the infection appearing not to have any The egg hatches into a nymph, which
effect on the flea and does not shorten its in all respects resembles a small adult,
lifespan. R. typhi is not transmitted by the and sucks blood. Three nymphal stages
bite of the flea, but is passed in its faeces. If are passed through before it becomes an
infected faeces are rubbed into an abrasion adult louse. Lice, both males and females,
or inhaled as an aerosol, other rats become can only survive by taking blood meals and
infected. The body of the flea is also highly if deprived, can last no longer than 10 days.
contagious and if crushed, the organism is They are sensitive to temperature and will
liberated. While X. cheopis is the main abandon a dead person as well as one with a
vector, the organism has been isolated from high fever. The lifespan of an adult louse is
Pulex irritans, the common human flea, lice, about 1 month and during this time, a female
mites and ticks. These probably do not form may lay some 200300 eggs.
an important means of transmission, but R. prowazekii is ingested in the blood
could explain epidemics where X. cheopis meal and can infect both males, females
is not found. and all nymphal stages. The rickettsiae de-
Humans are infected by their close velop in the epithelial lining cells of the
association with domestic rodents. When stomach, which they distend to such an
a flea is squashed or scratched into an extent that rupture takes place, liberating
abrasion, its tissue juices or faeces contam- them back into the damaged gut lumen.
inate the wound. The habit of some people These are then passed into the louse faeces
when catching fleas of crushing them in which they can survive for 100 days or
between their teeth is also a potential more. The damage caused to the louse can
method of infection. However, it would be sufficiently severe to kill it within 10 days
seem that the direct attack by the essentially and this helps to explain why few lice are
healthy rat flea is uncommon and the found on a person suffering from typhus.
more important method of transmission Humans become infected by scratching
is from an aerosol of organisms in the the louse faeces into abrasions or the punc-
flea faeces. These are carried on the rats ture wound left by the feeding parasite, or if
fur or sent into the air when disturbed. the lice is crushed on the skin or in the
R. typhi can be inhaled, swallowed or enter mouth. Dried lice faeces can remain viable
through other mucus membranes, such as for a considerable period of time and
the conjunctiva. Murine typhus is common fine particles that are inhaled or enter the
258 Chapter 16
conjunctiva can be a potential hazard to infection for weeks after they have died.
those not infested with lice. Fleas in murine typhus remain infected for
Lice thrive in conditions of deprivation life (about 1 year).
and poverty, where clothing is worn without
changing and people live in close proximity Occurrence and distribution Like plague,
to each other. Lice cannot travel far, or sur- typhus is a disease of history, particularly
vive for long without a blood meal, so it is the associated with the conflicts of man. When
crowding together of people that allows lice the anger of man causes war, disruption
to crawl across and infest a new host. Where of civilizations, famine and refugees, then
clothing is changed or washed, or the ambi- the disease of war, typhus, enters into the
ent temperature is high, body lice do not attack. At the present time, it is a particular
occur and typhus is not found. But, in times risk of refugee camps.
of human disruption brought about by war, Epidemic typhus can occur in highland
famine or social upheaval, the crowding to- areas, particularly during the rainy season
gether of people, in conditions of poor sani- with outbreaks occurring in Rwanda, Bur-
tation, provides the stage for an outbreak of undi, Ethiopia, Guatemala, Bolivia and
typhus. A similar situation can occur in the Peru. The three countries in Africa have
highland areas of tropical countries, where reported the most cases in recent times.
people live close to each other to keep warm. Murine typhus is endemic in Pakistan,
Various claims have been made for non- India and the Malaysian peninsula, but
human reservoirs of R. prowazekii, but may become epidemic in any part of the
humans appear to be an adequate reservoir world where rats are found, such as in
and the louse an ideal vector. The difficulty ports.
is what happens to the organism when an Mite or typhus islands are found in
epidemic has subsided? The probable East, South and Southeast Asia, including
answer is found in BrillZinsser disease, Siberia, China, Japan, Thailand, Pakistan,
more suitably called recurrent typhus. In Australia and Pacific Islands.
this condition, people are found to have
R. prowazekii in their bodies long after they Control and prevention of scrub typhus is by
had the disease. The organism remains dor- the wearing of clothing treated with repel-
mant until some event causes a breakdown lents or insecticides to prevent the larval
in host resistance and overt disease re- mite from attacking humans. Long trousers
appears. Cases have been found 20 and tucked into boots with high lace-up sides, or
40 years after the person was in a typhus gaiters to cover the gap, impregnated with
area and where lice have been absent for diethyltoluamide, dimethylphthalate or a
this length of time. But if lice are fed on synthetic pyrethroid. Repellents should also
these cases, they become infected and can be smeared on to arms and necks because it is
transmit epidemic typhus. these sites that are attacked when working in
the undergrowth. If an area of scrub typhus is
Incubation period is 12 weeks (up to known and it is desired to clear it perman-
3 weeks in scrub typhus). The incubation ently, then the undergrowth should be cut
period is related to the infecting dose. down and burnt, leaving the ground to thor-
oughly dry out before being safe to use. A less
Period of communicability Lice can become permanent method is to spray the area with
infected during the febrile illness, which insecticides. Tetracycline can be taken as a
may last for 2 weeks, but since lice will prophylactic by those at particular risk, but
leave a febrile person, it is probably only such methods are never reliable.
during the earlier part of the illness. Control of murine typhus is the same as
A chronic carrier (with BrillZinsser dis- for plague (Section 16.1) where the subject is
ease) can infect lice for up to 40 years. Lice covered in more detail. Essentially, it is the
excrete rickettsiae 26 days after an infected control of fleas and rats with the use of in-
blood meal, but continue to be a source of secticide powders to kill the fleas first,
Box 16.1 Rat control.
The control of rats can be by cats, traps or poisoning. Rat protection with shields and guards should be used
after rats have been removed. A well-trained cat can be most efficient. Trapping is an effective means of rat
control if carried out properly. Traps can be made out of scrap pieces of metal and are, therefore, simply
manufactured in developing countries. A knowledge of the rat runs is gained and the trap left baited, but
unsprung. Once the bait has been taken, then the trap is set. Traps must be visited regularly, all dead rats
disposed of (by burning) and set again.
Poisoning can be either with acute or chronic poisons. The number of poisons is considerable and
where available, it is preferable to solicit professional advice. Poisons strong enough to kill rats are also able
to kill other animals that may consume them. They are also dangerous to humans, especially children, so
proper safety precautions must be observed. Zinc phosphate is a useful acute poison. A good bait should be
used, such as broken maize or rice mixed in a proportion of 1:10 using cooking oil to dissolve it.
Alternatively, it can be mixed with water and bait, then dried out before applying to the traps. There is a
danger from the dust and gases produced when preparing baits, so mask and gloves should be used. Copper
sulphate is an antidote and can be administered in 0.25 g portions orally, every 10 min until vomiting is
induced. The most commonly used chronic poison is Warfarin, which is mixed with bait in a ratio of 1:19.
With chronic poisons, the bait should first be placed and only if it is taken, mixed with poison on subsequent
applications. Gassing is very effective as it kills both rats and fleas at the same time, but strict precautions
must be observed. Rodents living in burrows can be gassed, blocking all exits; hydrogen cyanide gas is most
commonly used.
followed by measures against rats. Buildings Prophylactic antibiotics, generally

should be protected against re-infestation tetracycline, can be given to contacts to
and new structures built with rat-proofing reduce the extent of the reservoir. Treatment
(Box 16.1). centres should be set up to discover cases
Control of epidemic typhus is control of early and antibiotics given.
the louse. In an epidemic, this is most effect- Vaccines have been successful in con-
ively done by blowing an insecticide trolling epidemics, but they suffer from vari-
powder into peoples clothing. This can be ous disadvantages. A killed vaccine (Cox) is
by a blower with a long nozzle that is pushed painful when injected and does not give
up the arms of clothing, down through necks complete immunity, whereas a live, attenu-
and up trousers and skirts. The clothing ated vaccine appears to give solid immunity
should be thoroughly treated remembering for over 5 years, but must be prepared care-
that the lice live between the underclothing fully as virulence can increase. Vaccines can
and body. Temephos (2%), propoxur (1%), either be used for mass administration in the
permethrin (0.5%) or other synthetic pyr- face of epidemics or be given to individuals
ethroids can be used. Samples of lice should at increased risk, such as medical personnel.
be tested for insecticidal resistance before In the long term, typhus will only dis-
and during mass treatments. Since it is con- appear when all lice are removed. People
ditions of overcrowding that generate epi- should be encouraged to wash themselves
demics, it is often not too difficult to and their clothes. Clothes must be boiled or
disinfect large numbers of people in a com- washed at over 708C, which is a higher tem-
paratively short time. Dead bodies should be perature than most washing machines
dusted with insecticides before burial. achieve. Ironing clothes kills both adults
A long-term preventive method is to treat and eggs.
underclothing with insecticides in the
same way as mosquito nets are treated, to Treatment should be commenced as soon as
give a target dose of 0:65---1 g=m2 permethrin. possible, even before the diagnosis is con-
Clothes can be washed, but treatment firmed, as speed is of the essence if treat-
should be repeated every 6 weeks. ment is to be effective. A single dose of
260 Chapter 16
200 mg doxycycline, irrespective of age, is mucous membranes and possibly even

the treatment of choice. Alternatively, tetra- unbroken skin. The greatest risk then is to
cycline at a dose of 500 mg four times a day the attentive parent or acquaintance delous-
may be given, and where both of these are ing a member of the family or a friend.
unavailable, chloramphenicol may be used. Sub-clinical infection must also occur
Careful nursing is of utmost importance. because the lice are killed even though the
person does not show any symptoms.
Surveillance is the cornerstone of preven- Humans are the only reservoir of the louse-
tion by conducting louse surveys at clinics, borne infection.
prisons, institutions and collections of
people. Cases of proven or suspect epidemic Incubation period 515 days, normally
louse-borne typhus should be notified to 8 days.
WHO. All contacts of a case should be
Period of communicability Humans are most
placed under surveillance for 14 days.
infectious during periods of pyrexia, but as
reservoirs, they can infect lice at any time.
The louse becomes infectious 45 days after
16.3 Louse-borne Relapsing Fever an infected blood meal.
Organism Borrelia recurrentis, a spirochaete Occurrence and distribution The disease is

indistinguishable from B. duttoni in stained associated with poor personal hygiene and
preparations, and with some cross-immunity overcrowding, in which lice flourish. Distri-
between the two. bution is similar to epidemic typhus, being
found in the highland areas of Africa, India
Clinical features Louse-borne relapsing and South America. There is an endemic
fever is an epidemic disease occurring in focus in Ethiopia from which epidemics
the same situations or even at the same appear to originate, all the conditions being
time as epidemic typhus. The disease is favourable about once every 20 years.
very similar to tick-borne relapsing fever
(see below), with periods of fever lasting Control and prevention is the same as for
for a few days and then recurring after epidemic typhus above, with delousing
24 days, but the number of relapses is gen- and improvement of hygiene.
erally less. The onset of fever is sudden with
Treatment is with a single dose of procaine
headache, myalgia and vertigo. A transitory
penicillin (300,000 units) on the first day,
petechial rash can occur and other symp-
followed by tetracycline 250 mg on the next
toms, such as bronchitis and hepato-
day. Severe reactions to antibiotic therapy
splenomegaly, may develop.
are commoner in louse-borne than tick-
borne relapsing fever.
Diagnosis is by darkfield illumination of
fresh or stained blood taken during a pyr- Surveillance Cases of louse-borne relapsing
exial episode. fever must be notified to WHO and neigh-
bouring countries. Routine inspections for
Transmission Pediculus corporis humanus lice should be carried out where facilities
is infected when it feeds on humans during permit, such as in prisons, institutions and
the pyrexial period, the spirochaete invad- to new arrivals coming into refugee camps.
ing the haemocoel of the louse.
The spirochaete is not transmitted when
the louse feeds, but when it is crushed, the 16.4 Tick-borne Relapsing Fever
Borrelia entering the bite wound or any abra-
sion. Crushing lice between the fingernails Organism Borrelia dutoni, which is
or teeth are possible ways of acquiring infec- indistinguishable from B. recurrentis in
tion. The spirochaete can also enter through stained blood films.
Clinical features Fever develops with a re- However, immunity is lost by pregnancy
curring or relapsing pattern as the name of and congenital infection can occur. Relaps-
the disease indicates. The period of fever ing fever is a cause of abortion, stillbirth and
lasts for a few days and then recurs after premature delivery. This is particularly the
25 days, with up to ten or more relapses pattern in Central and East Africa.
occurring in the untreated case. The onset In other parts of the world, the infection
of fever is sudden with headache, myalgia is a zoonosis with a transmission cycle
and vertigo; a transient petechial rash can maintained between rodents and their para-
occur and a variety of other systems may be sitic ticks. People enter this cycle as
involved. There can be bronchitis, nerve intruders or by accident in a similar way to
palsies, hepato-splenomegaly and signs of sylvatic plague or scrub typhus. Rodent-
renal damage. inhabited caves or campsites near rodent
burrows are areas where sporadic infection
can occur. When temporary shelters or log
Diagnosis Spirochaetes are found in the
cabins are erected near a zoonotic focus, rats
blood during febrile periods when blood
invade these buildings and their ticks begin
slides should be taken and either stained or
to feed regularly on humans. An endemic
viewed by dark ground illumination. An im-
pattern, similar to that in Africa may then
provement on this technique is the direct
develop. Ticks responsible for transmitting
centrifugal method.
relapsing fever in other parts of the world are
O. tholozani in Asia, O. erraticus in North
Transmission, occurrence and distribu- Africa, and O. rudis and O. talaje in Central
tion Two different patterns of tick-borne re- and South America.
lapsing fever occur; an endemic in Africa Soft ticks (Argasidae) have a retracted
and epidemic in other parts of the world head and no scutum, which differentiates
(Fig. 16.4). them from hard ticks (see below). As their
In Africa, the vector Ornithodorus mou- name implies, soft ticks do not have a
bata is domestic in habit living in and rigid structure, but a leathery body that
around the home, transmitting the disease looks like a collapsed bag. This hangs over
within the household. The reservoir is the the body structures, so viewed from above
tick, but humans act as a source of organ- only the legs can be seen protruding from
isms. When a tick feeds on an infected it (Fig. 16.4). When the tick takes a blood
person, spirochaetes are ingested with the meal, its collapsed body fills and becomes
blood, multiply in the gut and enter the greatly distended. The tick digests the blood
haemocoel, where they increase to enor- meal utilizing a structure called a coxal
mous proportions. The spirochaetes pierce gland, which is like a filter to remove excess
all organs of the ticks body, including the fluid.
salivary gland, the coxal organ and the re- After hatching, there are several
productive system, leading to transovarial nymphs (four in O. moubata), each needing
infection. Nymphal stages may already be to take a blood meal before passing on to the
infected when they take blood meals or can next nymphal stage. Finally, the fourth
become so from their hosts. People are instar changes into an adult and egg laying
infected both by the bite of the tick and commences after the female has become
from the coxal fluid (see below), but not engorged with blood. Ticks can live for sev-
from the faeces. In O. moubata adults, the eral years so that many eggs can be laid in a
coxal fluid is the main source of spiro- lifetime. In contrast to hard ticks, the female
chaetes, but in the nymphs and other does not die after egg laying, but is able to
species of Ornithodorus, it is the salivary continue taking blood meals, laying eggs
glands. after each meal.
Babies and young children are particu- Ticks rest in cracks and crevices of
larly susceptible to infection in endemic poorly built houses, emerging at night to
areas, with adults exhibiting immunity. feed on sleeping occupants. They can
262
Cave or temporary shelter
Tick taking blood meal on sleeping person
Ticks inhabiting cracks in wall and floor Rodent tick biting human
Endemic variety (Africa)
Epidemic
Chapter 16
Rodent and its variety
ticks living in burrow
Ornithodorus moubata Soft tick
page 262
Fig. 16.4. The vector and epidemiology of tick-borne relapsing fever.
remain alive for up to 5 years after a single Surveillance Mass screening using fresh or
blood meal and are able to attack again after stained blood slides can be used to delineate
the owner re-occupies a house following a the infected population prior to a control
prolonged absence. The eggs are coated with programme.
a waxy protective layer allowing them to
remain viable for several months laid in
walls, floors and furniture, they will hatch
16.5 Diseases Transmitted by Hard
in 14 weeks if conditions are suitable. Soft
ticks once established are very persistent Ticks
occupants.
16.5.1 Hard ticks (Ixodidae)
Hard ticks are responsible for transmission
of several different kinds of organisms in-
Period of communicability All stages of the cluding rickettsiae, Borrelia and arbo-
tick are able to transmit infection and they viruses. The genera of medical importance
remain infective for life. are Amblyomma, Dermacentor, Haemaphy-
salis, Hyalomma, Ixodes and Rhipicepha-
Control and prevention Ticks can be con- lus. A female Dermacentor, to characterize
trolled with insecticides, such as malathion, the group of hard ticks, is illustrated in Fig.
diazinon, permethrin or propoxur, sprayed 16.5. The feature that distinguishes hard
around houses. Special attention needs to be from soft ticks is the presence of a scutum
paid to any cracks and crevices where ticks (shield) and protruding mouthparts. Care
may hide. In addition, insecticides can be has to be taken in identifying the engorged
mixed with the floor or wall plaster during specimen, for the body is so greatly dis-
construction or repair work. BHC as 140 mg tended as to obscure the head and mouth-
base/m2 is a suitable preparation. Infants parts (Fig. 16.5). The female has a smaller
(and adults) can be protected from house- scutum than the male, but since both males
invading ticks by sleeping under a mosquito and females take blood meals, there is no
net. Repellents, such as DEET or need to distinguish between them.
dimethylphthalate smeared on skin or as a Eggs are laid in a large mass on the
solution to impregnate clothing, are effect- ground, hatching after weeks or months
ive in preventing ticks from biting. Items, into six-legged larvae. These larvae resemble
such as socks, can be treated with insecti- mites, but are differentiated from them by
cides in the same way as mosquito nets (see prominent mouthparts and a scutum. The
Sections 3.4.1 and 3.4.4). Ticks are also de- larvae climb on to grass or prominent vegeta-
terred from entering rooms in which a night- tion to await a passing mammal on to which
lamp is glowing. they cling. Once attached, they crawl around
The rodent reservoir is of major to find an area of soft skin, such as in the ears,
importance in bringing ticks close to human eyelids or belly of an animal. On humans,
habitation so all the methods mentioned in they may surreptitiously climb up the
plague (Box 16.1) to control rodents should leg and attach themselves to the scrotum or
be used. Improved house construction between the buttocks. Once in a favourable
will prevent rodents from burrowing under- site, they pierce the skin with their powerful
neath. mouthparts, inject saliva and feed on the
hosts blood. Larvae will remain attached
Treatment is with a single dose of 300,000 for 37 days, after which they drop to
units of procaine penicillin immediately, the ground and seek a place to moult. De-
followed the next day by tetracycline veloping into an eight-legged nymph, the
500 mg four times daily for 10 days. This nymph repeats the feeding pattern, being
regime provides adequate treatment, while attached for 510 days and then falling to
at the same time minimizes reactions. the ground once more for the final moult.
264 Chapter 16
Fig. 16.5. Characteristics of hard ticks.
From the nymph develops a male or female if it becomes too cold, the cycle of develop-
adult, which subsequently quests for a new ment will be delayed until more favourable
host on which it remains for a considerable conditions return. Larvae and nymphs tend
period of time (up to 1 month) becoming to feed on small mammals and humans,
greatly engorged with blood. Finally whereas adults prefer larger animals, such
dropping off, the female digests her blood as cattle and game animals.
meal and begins egg laying, after which she
dies. Control of ticks is mainly through the use of
The life cycle of ticks is modified insecticides and repellents. Permethrin,
by temperature and humidity, such that malathion and propoxur are suitable insecti-
cides, administered as dusting powders or eralized maculo-papular rash, resolving

solutions to infested animals. Cattle are spontaneously after about 1 week.
commonly treated by making them swim
through an insecticidal bath or dip. This Diagnosis is usually on clinical appearance
should be carried out on a regular basis, following history of a tick bite, but can be
with monitoring of ticks for insecticidal re- confirmed with serological tests or PCR.
sistance. Dogs are important carriers of ticks
and should be similarly treated by insecti-
cidal baths, making sure that they are totally Transmission The reservoir of infection is
immersed as the ears are a common site the dog tick (Rhipicephalus sanguineus in
for ticks to attach. Dogs should wear tick- the Mediterranean area, and Amblyomma
repellent collars. hebreum in Africa), which inadvertently
Repellents, such as diethyltoluamide moves from the dog to its human handler
or dimethylphthalate smeared on skin or during their close association. Alterna-
as a solution to impregnate clothing, are tively, humans acquire infection from pass-
effective in preventing ticks from becoming ing through scrub forest inhabited by
attached. Items, such as socks, can be rodents and their ticks (Ixodes holocyclus
treated with insecticides in the same way in Australia, Dermacentor and Haemaphy-
as mosquito nets (see Sections 3.4.1 and salis in Siberia), the rodent serving as a sec-
3.4.4). ondary reservoir.
Ticks take nearly 2 h to attach them-
selves and start feeding, so a careful search Incubation period 115 days (generally
of the body, paying particular attention to 57 days).
the upper legs, groin and buttocks, should
be made after passing through tick-infested
country. Larval and nymph stages can be
from human-to-human, the tick remaining
very small. Ticks should not be pulled off
infected for life.
directly as the mouthparts may be left
behind, which will continue to cause irrita-
tion. Applying methylated spirit, ether, ben- Occurrence and distribution Found in
zene or similar solutions will kill the tick slightly different forms in the Mediterra-
and sterilize the wound. nean region, Africa, Indian sub-continent,
Australia and northeast Asia.
Control and prevention Where the dog is

16.6 Tick Typhus/Fever the carrier of ticks, they should wear tick-
repellent collars and be inspected regularly
Going under a host of names, Boutonneuse to ensure the animal is tick-free. In Australia,
fever, Mediterranean-spotted fever, African Siberia, Mongolia and northern China
tick typhus, Indian tick typhus, Siberian tick where rodents and small marsupials are
typhus, Queensland tick typhus, to give but mainly responsible, repellents and insecti-
a few, this similar group of infections has cide-treated socks and trousers should be
been reported from different parts of the worn. Since it takes the tick about 2 h to
world. fully attach itself, it is always a good practice
to examine the body carefully after going
Organism Rickettsia conori, R. africae, through tick-infested country. When camp-
R. siberica and R. australis. ing, people should sleep off the ground (e.g.
on camp beds) and dogs should be kept
Clinical features Generally, a mild illness of away.
a few days, infection is characterized by an
eschar at the site of the tick bite and regional Treatment is with tetracycline, doxycycline
lymphadenopathy. There is fever and a gen- or chloramphenicol.
266 Chapter 16
Surveillance Make a regular habit of examin- with tick-repellent collars is effective.

ing the body after walking through country- Amblyomma cajennense is the main vector
side. in the rest of the Americas.
Treatment is with doxycycline, tetracycline

16.7 Rocky Mountain Spotted Fever or chloramphenicol.
Surveillance Dogs and other animals should

Organism Rickettsia rickettsii.
be checked regularly for ticks.
Clinical features The illness commences

suddenly with onset of high fever, head-
16.8 Lyme Disease
ache, malaise, muscle pains and rash.
Appearing about the third day, the charac-
teristic rash is maculo-papular from numer- Organism Borrelia burgdorferi, B. garinii
ous petechial haemorrhages and covers the and B. afzelii.
whole body including the palms and soles.
Clinical features The herald sign is an annu-
lar expanding erythematous skin lesion,
Diagnosis is made clinically with the add-
called erythematous migrans (EM), often
itional help of enzyme immunoassay and
accompanied by fever, muscle pain, arthral-
immunofluorescence tests containing the
gia and signs of meningeal irritation. Infec-
specific antigen.
tion may develop over weeks or months into
aseptic meningitis, encephalitis, peripheral
Transmission Humans are infected by the nerve signs, cardiac irregularities and poly-
bite of a tick although infection can also be arthritis.
acquired by scratching in tick faeces or
crushing the tick on the skin or mucous Diagnosis is mainly clinical, the EM lesion
membranes. Larval and nymphal stages, as exceeding 5 cm, aided by serological tests,
well as adult ticks, can transmit the infec- more useful in the later stages of the disease.
tion. Rickettsial infection is maintained by
transovarial transmission and the tick acts Transmission is from the bite of an infected
as the reservoir. deer tick, Ixodes scapularis or I. pacificus, in
North America or sheep tick I. ricinus in
Incubation period 314 days. Europe. In Asia, I. persulcatus is the vector.
The reservoir of infection is in the tick,
Period of communicability Since the tick is which can transmit the Borrelia transova-
the reservoir of infection, it is not spread rially. Adult ticks largely feed on deer
from person to person. (sheep in Europe), while the nymphal stage
is responsible for transmitting the infection
to humans and other animals, such as dogs,
Occurrence and distribution First described
which will often develop similar symptoms
in the Rocky Mountains of North America,
to humans.
the disease is also found in Mexico, Panama,
Costa Rica, Brazil, Colombia and Argentina.
Incubation period 332 days (mean 710
days).
Control and prevention Prevention is
by avoiding any known tick country or
wearing protective clothing, treated with Period of communicability Not transmitted
repellents or insecticides. The common from person to person.
vector in North America is the dog tick, D.
variabilis, or the wood tick D. andersoni so Occurrence and distribution Found in well-
the control of dogs and their ectoparasites defined areas of USA and Canada, largely
related to the deer population. Limited Transmission is by Haemaphysalis spini-

range in Europe, Russia, China and Japan. gera, with a reservoir in rodents and
Foci of infection can be delineated by monkeys in KFD and Dermacentor reticula-
looking for the vector tick. tus and D. marginatus in OHF. The muskrat
is the reservoir, so hunters are the main
Control and prevention are similar to other victims from which they can also acquire
tick-borne diseases mentioned above with infection directly.
the use of repellents and insecticide-treated
clothing when passing through known Incubation period 38 days.
infected areas. Since transmission of infec-
tion takes in excess of 24 h after the tick has Control is the same as the other tick-borne
attached, careful search of the body should diseases. Experimental vaccines are under
be made after walking through countryside. trial.
The nymphal stage is the main transmitter to
humans so small black spots should be
looked for, possibly with the aid of a lens
(see Fig. 16.4). 16.9.2 CrimeanCongo haemorrhagic fever
A vaccine has been developed against
lyme disease in North America, but is not CrimeanCongo haemorrhagic fever virus
effective in other parts of the world. It is only is related to dengue and yellow fever
useful for persons at constant risk of infec- with which it shares a similar clinical pre-
tion, such as game wardens or camp attend- sentation (Sections 15.4 and 15.5). It is
ants, but other precautionary measures found in a wide area stretching from west
should also be taken. and southern Africa through central and
northeast Africa into the Arabian peninsula,
Treatment is effective with doxycycline or to west and central Asia (Iraq, Iran, Pakistan,
amoxicillin in the early EM stage of the dis- Afghanistan, Russia and west China) and
ease. In the late arthritic, cardiac or neuro- westwards into the Balkans and Greece.
logical stage of the disease, treatment is with
benzylpenicillin or ceftriaxone for up to Transmission is by Hyalomma marginatum
21 days. and H. anatolicum ticks, which also serve
as reservoirs, although birds, rodents
Surveillance Infected areas should be and hares may be involved. Person-
delineated and warning signs posted. to-person infection can also occur from ex-
posure to blood and other body fluids. The
ticks feed on domestic animals (cattle, sheep
16.9 Arboviruses and goats), so the disease is an occupational
hazard of farmers and shepherds, who can
16.9.1 Kyasanur forest disease (KFD) and also contract the illness by contact with
Omsk haemorrhagic fever (OHF) animal tissues and fluids.
KFD is named after the forest in Karnataka, Incubation period 13 days, but can be up to
South India where an epidemic was first 12 days.
identified in 1983. A very similar disease,
OHF, is restricted to western Siberia. The or- Period of communicability During the entire
ganisms and clinical features are described period of illness, the patient is highly infec-
with the other arbovirus haemorrhagic fevers tious from urine, blood and other body
in Section 15.2. fluids.
268 Chapter 16
Control and prevention All the precautions

mentioned above should be taken to prevent 16.9.3 Other arbovirus diseases
being bitten by ticks, including insecticide
treatment of domestic animals. Strict barrier Hard ticks can also be responsible for
nursing should be observed with all cases. spreading other arbovirus diseases normally
Gloves and overalls should be worn when transmitted by mosquitoes, such as Japanese
working with animals. People in high-risk encephalitis and St Louis, Eastern and West-
areas can be vaccinated. ern equine encephalitis (see Section 15.2).
17
Domestic and Synanthropic Zoonoses
A zoonosis is an infection that is naturally covered in some detail in the section on

transmitted between vertebrate animals and plague (Section 16.1), but also involved in
humans. In the last chapter, a group of infec- several other infections mentioned in this
tions that were mainly zoonoses, but also chapter. Control depends upon an under-
involved a vector were covered, while this standing of the contact with the animal and
chapter includes infections in which a how best to reduce it.
vector is not involved. Most of these infec-
tions are due to the close association
humans have with their domestic animals,
17.1 Rabies
but there are also some zoonoses in which
animals that live close to humans, but are
not welcomed, such as rats, are involved in Organism Rabies is caused by a rhabdovirus
the transmission of disease. These are called in the genus Lyssavirus. There are seven re-
synanthropic zoonoses. Some zoonotic in- lated viruses, including Mokola and
fections have been covered in earlier chap- Duvenhage (found in Africa), which pro-
ters where the means of transmission and duce rabies-like illness. The virus with-
control are similar to other allied condi- stands freezing temperatures for
tions, for example, the pork and beef tape- considerable periods of time, but is killed
worms will be found in Section 9.8 under by boiling, sunlight and drying. It is not
food-borne diseases. easily destroyed by disinfectants.
The most important source of infection
from which humans suffer is from other Clinical features The disease starts quietly
humans, but the animals on which people with malaise, fever, sore throat and lack of
depend for their livelihood and companion- appetite; paraesthesia develops and abnor-
ship are responsible for many others. Para- mal muscle movements occur. The patient
mount amongst these is the dog, which is then enters the excitable stage when they
involved directly in a number of diseases, become anxious, there is difficulty in swal-
or is a reservoir for many others (Table 17.1). lowing and frank hydrophobia and general-
Less important, except to people who have ized convulsions may take place. The
close association with them are cats, cattle patient either dies in the convulsive stage
and other domestic animals. The principal or enters progressive paralysis as the ter-
synanthropic vector is the rat, already minal symptom. In the bat-transmitted
269
270 Chapter 17
Table 17.1. Infections transmitted to humans from dogs or in which the dog is a reservoir.
Viruses Arboviruses
Rabies
Rickettsiae R. rickettsii, R. conorii, R. africae, R. australis, R. siberica
Bacteria Anthrax
Brucella canis
Campylobacter jejuni
Capnocytophaga
Escherichia coli
Leptospirosis
Mycobacteria
Pasteurellosis
Salmonella
Spirillum minus
Tularaemia
Fungi Ringworm
Protozoa Chagas disease
Cryptosporidiosis
Isospora belli
Leishmaniasis
Helminths Ancylostoma (larva migrans)
Brugia malayi, B. pahangi, B. patei
Diphyllobothium latum,
Dipylidium caninum
Dirofilaria immitis
Dracunculus medinensis
Echinococcus granulosus, E. multilocularis, E. vogeli
Echinostoma
Gnathostoma spinigerum
Heterophyes heterophyes
Metagonimus yokagawai
Multiceps multiceps
Opisthorchis sinensis, O. felineus
Paragonimus westermani
Strongyloides
Schistosoma japonicum
Toxocara canis
Arthropods Fleas
Ticks
Pentastomids (Linguatula)
form of the disease, there is no excitable staining of tissue smears (e.g. skin biopsy)
stage and the patient dies from respiratory is of value.
paralysis.
Transmission Virus enters the body through
a bite or abrasion of the skin. Classically, it is
Diagnosis The clinical picture following a a dog bite, but if an infective dog, cat or cow
history of an animal bite is usually sufficient licks the abraded skin, then transmission
to make the diagnosis, but the virus may be can occur in this manner. The vampire bat
isolated from saliva, tears, CSF, urine and also transmits rabies, but mainly to cattle,
many other tissues if facilities exist to cul- with humans only occasionally infected
ture it. Immunofluorescence antibody this way. People have contracted rabies by
Domestic and Synanthropic Zoonoses 271
entering bat-infested caves where it is the virus to the brain and the size of the
thought that fine particles of bat faeces con- infective dose. It is usually 212 weeks, but
taminate the conjunctiva or enter the can be years in young children with a minor
respiratory mucosa. bite.
The virus has a special affinity for brain
and mucous-secreting tissue, travelling Period of communicability Theoretical
along peripheral nerves to the CNS and transfer from person-to-person is possible,
salivary glands. Large quantities of virus so barrier nursing should be instigated.
particles are present in the saliva from 1 to Animals are infectious from 4 to 14 days
10 days before the development of symp- before clinical signs start until they die or
toms in the animal, right up until it dies. are killed, but their saliva remains infec-
The disease in the dog occurs in two tious. Sixty per cent of persons bitten by
forms, the furious and dumb. In furious a known rabid animal do not contract the
rabies, the animal becomes restless, disease.
wanders away from home and bites anybody
or anything that comes in its way. It is Occurrence and distribution A disease that
unable to bark, may attempt to eat sticks strikes terror into people, it is widely spread
and stones, but is foiled in the attempt by a throughout the world, as important in tem-
difficulty in swallowing. It foams at the perate as tropical countries. It is common in
mouth and suffers from the progressive par- Russia, Africa, Asia and South America.
alysis of dumb rabies and is dead within a India reports 30,000 deaths per annum,
few days. Sometimes the furious course is more than half the total cases in the world,
not followed and dumb rabies only is mani- with other countries in Asia accounting for
fest. most of the rest. It is particularly dangerous
While the disease is invariably fatal in to children aged 515 years who are the
domestic dogs, cats and cows, it would main victims.
appear to have a more variable effect It is mainly transmitted by dogs, includ-
in wild dogs, such as foxes and wolves. Cer- ing wolves, foxes, jackals and hyenas, but
tainly, rabies controls fox populations, but the cat and cow have also been responsible.
individuals do recover from the disease. Other infected wild animals are mongooses,
There is little evidence to support the find- skunks and raccoons. In South America, the
ing of a reservoir in such canines, but this vampire bat transmits rabies particularly to
may not be the case in rodents and bats. cattle, but insectivorous and fruit-eating
Rabies virus has been found in mongooses bats have also been found infected.
and the multimammate rat, Mastomys nata-
lensis. These animals suffer from rabies, but Control and prevention Control measures
sub-clinical infections may occur. When can be aimed against the domestic dog, the
canines feed on small mammals they can reservoir in wild animals, and the protection
acquire rabies. Vampire bats have been of humans.
shown to recover from the disease and rabies Domestic dogs should be licensed and
virus has also been isolated from insectivor- vaccinated, destroying all the stray ones.
ous bats, which do not take blood meals. Vaccination of all domestic animals with
This suggests that rabies may exist in a an approved vaccine should be mandatory
mild and asymptomatic form for most of in all endemic areas.
the time in these mammals, but when they Control of the wild animal reservoir is
bite or people enter their virus-contamin- a massive undertaking, but alteration of
ated habitat, they are at risk of losing their habitat and local destruction around dwell-
life (see further Section 18.3). ings or place of work can be practised. As
rabies follows a natural cycle in many wild
Incubation period depends upon the animals, their total destruction over large
proximity of the point of introduction of areas may upset this balance and produce a
272 Chapter 17
rebound increase, so it is preferable to try has died or was killed, then the head is
and maintain this balance by using vaccin- severed with aseptic precautions (as the
ation. This has been effectively used in saliva is highly infectious), packed in ice
Europe and Canada by leaving vaccine and sent to a laboratory for viral antigen
baits for wild animals to take. With bat testing or histological studies. Section of
rabies, control of bats is largely unsuccessful the brain will show characteristic Negri
and it is preferable to immunize cattle, bodies.
which are the main victims. Post-exposure vaccination can be given
People who are at special risk, such as with HDCV, VCV or PCEC immediately and
veterinarians, animal handlers and those on days 3, 7, 14, 28 and 90. If pre-exposure
working with bats, can be vaccinated with immunization was given, then give one dose
human diploid cell vaccine (HDCV), Vero immediately and a second in 3 days. The
cell vaccine (VCV) or purified chick embryo normal dose is 1 ml intramuscularly, but
cell vaccine (PCEC). Adverse reactions because of the high cost, money can be
do occur so the vaccine should only be ad- saved by giving much smaller doses (0.1 ml
ministered to those at risk of exposure to of HDCV) intradermally.
rabies. The vaccine is given on days 0, 7 Hyper-immune anti-rabies serum is
and 28 with a booster after 1 year. If the given as soon as possible, half around the
risk continues, then boosters every 5 years wound and the rest intramuscularly. Human
are recommended, although protection immune globulin is preferable, but if horse
probably is maintained for 10 years with serum only is available, then a test dose
HDCV and VCV. must first be given. The dose is:
Because children in the 515-year
age group are at the greatest risk of dying . human immune globulin, 20 IU/kg body
from rabies, some countries may consider weight;
vaccinating children between 2 and 4 . animal immune globulin, 40 IU/kg body
months of age. To save costs, three doses weight.
of 0.1 ml HDCV by the intradermal route at
2, 3 and 4 months of age may be more Table 17.2 summarizes the procedure to be
feasible. followed in treating a person who has been
attacked by a rabid animal.
Treatment Fortunately, rabies virus can be
inactivated on its passage along the periph- Surveillance Cases of rabies should
eral nerves and this is the main method of be reported to WHO. Countries should
protecting the individual bitten by a rabid work towards a system of vaccine certifica-
dog. The first procedure is to wash out the tion of dogs using microchip implants or
wound thoroughly with soap or detergent permanent collars containing vaccination
under running water, followed by a quater- details.
nary ammonium compound or 0.1% iodine.
Any alcohol, such as whisky or gin, can be
used if there is nothing else available. If
there is a high suspicion of infection, then 17.2 Hydatid Disease
rabies antiserum should also be injected
locally around the wound. Tetanus toxoid Organism Echinococcus granulosus, a
and penicillin should be administered, as cyclophyllidean tapeworm of canines.
tetanus is often a greater danger from a bite
than rabies. Clinical features Hydatid cysts, the inter-
If the biting animal can be caught, then mediate stage of the parasite, have been
it should be tied up and observed for 10 recorded from all parts of the human body.
days. After this time, it would either have The commonest site is the liver, with lung,
died from the disease or remained well. If it abdomen, kidney and brain in descending
order of frequency. As the cysts increase in fed the offal of domestic animals. In the
size, they can cause serious problems some wild, jackals, wolves and wild dogs become
times fatally. The cyst contents are infective infected by killing and eating infected herbi-
so if it ruptures either accidentally or at op- vores.
eration, then numerous new cysts are Humans enter this cycle accidentally by
formed. The liberation of so much foreign swallowing the eggs either:
protein in the body can result in a severe
anaphylactic reaction. . through food items (e.g. fruit or vegetables
contaminated by dog faeces);
Diagnosis of the disease is clinically, from . drinking water contaminated by dog
enlargement of liver or discovery of a cyst faeces;
on chest X-ray. Immunological methods are . close contact with dogs (e.g. by touching
useful. A diagnostic aspiration of the cyst their fur or being licked by them; when a
must never be made. dog licks itself, it can spread eggs all over
its body as well as sticking to its tongue).
Transmission Eggs passed in the dog faeces
contaminate pastureland and when eaten by
Primary infection commonly occurs in
sheep, pigs, goats, cattle, camels and horses
childhood, with symptoms developing in
develop into hydatid cysts (Fig. 17.1). The
adult life.
hydatid cyst is a fluid-filled sack containing
enormous numbers of scolices, any of which
can become an adult worm in the dog. The Incubation period Generally a period of sev-
common means of infection is for dogs to be eral years.
Table 17.2. Post-exposure and anti-rabies guide. This is only a guide and should be used in conjunction
with local knowledge of rabies endemicity and the animal involved.
Type of animal Status of animal Type of exposure Treatment
Domestic Healthy and remains so Any None

for 10 days
Dog Signs suggestive of Mild, scratch or lick Rabies vaccine (discontinue if
Cat rabies. Retain animal Bite animal not rabid by day 5)
Cow for 10 days
Rabid or becomes so Mild, scratch or lick Rabies vaccine
during retention
Bite Anti-rabies serum plus vaccine
(discontinue if animal not
rabid by day 5)
Escaped, killed or Mild, scratch or lick Rabies vaccine
unknown
Bite Anti-rabies serum, plus
vaccine
Wild Regard as rabid if Bite Serum immediately followed by
unprovoked attack course of vaccine
Fox
Wolf
Raccoon
Mongoose
Bat, etc.
274 Chapter 17
Eggs swallowed
by human
7%
10%
Adult worm in dog
66%
7%
8% Dog eats
infected
animal
Eggs passed offal
in dog faeces
Fig. 17.1. Hydatid disease, the life cycle of Echinococcus granulosus.
Period of communicability Dogs are often re- touching them or feeding them at meal
peatedly infected so continue to be a source times, destroying unwanted animals and
of infection, especially to children. observing personal hygiene. Children, in
particular, should be taught to wash their
Occurrence and distribution The disease is hands before eating and after touching dogs.
widespread, but occurs in concentrated
pockets, such as sheep-rearing areas or Treatment Albendazole and mebendazole
where dogs live in close proximity to are effective, but where necessary surgical
humans. A very high rate of infection is removal may be required, taking care to
found in the Turkana people of northern remove the entire cyst or if rupture seems
Kenya where dogs are trained to care for likely to sterilize the contents with formalin.
young children. Praziquantel will prevent the development
of secondary cysts if rupture of a primary
Control and prevention can be implemented cyst has taken place, so is a useful precau-
at several points in the life cycle: tion during surgery.
Infected material should not be fed to A similar, but rare infection is E. multi-
dogs or if this cannot be avoided, it must be locularis, which as its name suggests
well cooked. Dogs can be treated with prazi- forms multi-loculated lesions rather than
quantel to remove any adult worms. Meas- single cysts. These invade the body much
ures should be taken to reduce faecal in the same way as a neoplastic growth,
contamination, such as fencing water including producing metastases. It is found
sources and food gardens or the general in the colder regions of the world (Siberia,
training of dogs. Ultimately though control Alaska and northern Canada), a parasite of
will depend upon human attitude to dogs by foxes and dogs, with voles, lemmings and
keeping them in an appropriate place, not mice being intermediate hosts.
Another variety, found in Colombia, close association with humans, especially

Ecuador and Brazil, is E. vogeli, caught as pets.
by dogs eating agoutis, pacas and spiny
rats. A polycystic hydatid cyst results. Control and prevention Dogs should
be prevented from promiscuous defecation
of playgrounds, streets, parkland and vege-
17.3 Toxocariasis table gardens. Owners of pets should
scoop-up faeces and dispose of them safely.
Stray animals, especially unwanted pup-
Organism The roundworms of dogs, Toxo-
pies, should be destroyed. Dogs and cats
cara canis and less commonly cats,
should be dewormed at 6-month intervals
T. catis.
starting when the animal is 3 weeks old.
Young children should not play with pets
Clinical features Larvae unable to complete and should be taught personal hygiene from
their development in the human a young age.
body wander until they die. The body re-
sponds to this invasion by the production Treatment Albendazole and mebendazole
of eosinophils, but more serious is the tissue are used in treatment of the acute case, but
in which the larvae go to, an unfortunate site will not cure eye damage.
of predilection being the eye, which can
result in blindness. In heavy infections,
there is fever, cough, an urticarial rash and
hepatomegaly. 17.4 Larva Migrans
Diagnosis can be made with larval antigen Organism The larval form of several animal
ELISA. parasites wander aimlessly in the human
body, if they enter it by mistake. Examples
are the cat and dog hookworms, Ancylostoma
Transmission Eggs are accidentally ingested
brasiliense, A. stenocephala and A. canium,
from the dogs fur, from contaminated soil or
producing a condition called creeping erup-
from vegetables contaminated by dog faeces.
tion; and the cat and dog filariae, Dirofilaria
The typical picture is of the young child
immitis, Brugia pahangi and B. patei, which
playing with soil frequented by pet dogs
cause the more serious disease of visceral
and putting the fingers in their mouth. The
larva migrans. Bayliscaris procyonis, a
eggs are resistant to desiccation and remain
roundworm of raccoons, can result in fatal
in the soil for many months so that the soil in
encephalitis.
parks and other areas where dogs are taken
for walks can be heavily contaminated.
Clinical features Creeping eruption is often
visible as serpiginous tracks just underneath
Incubation period Transient infection may
the skin, which contain wandering larvae.
occur after a few weeks, but more serious
These are painful and red at the advancing
eye complications will probably not present
end, causing intense pruritus, and advan-
until the child is 5 years or older.
cing a little each day, sometimes continuing
for several years.
Period of communicability Although the in- In larva migrans the body reacts to the
fection is not transferred from one human to wandering parasites, especially when they
another, the eggs may be from unhygienic pass through the lungs, with a profound
habits. eosinophilia, one of the causes of the condi-
tion known as pulmonary eosinophilia.
Occurrence and distribution Worldwide, Symptoms are a paroxysmal cough, not
wherever dogs and cats are found living in unlike asthma, with the production of large
276 Chapter 17
quantities of sputum, sometimes streaked Treatment Larva migrans responds dramat-

with blood. A diagnosis of tuberculosis can ically to DEC, while albendazole or ivermec-
mistakenly be made. tin can be used in creeping eruption.
A localized form of visceral larva
Diagnosis is largely made on clinical migrans occurring in Thailand and China
grounds, but the filaria antigen of D. immitis results from Gnathostoma spinigerum, an
can be used as a skin test in larva migrans. intestinal parasite of cats and dogs. People
are infected by the larval stage, through
Transmission The animal hookworm larvae eating raw fish. The disease presents as a
are contracted in the same way as human single migratory swelling, either superfi-
Ancylostoma infection (Section 10.3), cially or in the deeper tissues, cerebral
walking without adequate foot covering in lesions being not uncommon. It causes in-
an area of soil contaminated by dog and cat tense itching and eosinophilia. If the larva
faeces. The filarial worms are transmitted by comes near the surface of the body, its surgi-
culicine mosquitoes, but as with human dis- cal removal can result in cure, otherwise
ease repeated infection is required. The rac- albendazole, mebendazole and DEC have
coon roundworm is deposited in frequently been reported to have some effect. Ensuring
used defecation areas, which can be associ- that fish are properly cooked is the easiest
ated with urban structures, such as rooftops, method of control.
attics, woodpiles and in gardens close to
trees, where humans, especially children,
inadvertently pick up the eggs and swallow 17.5 Toxoplasmosis
them.
Organism The coccidian protozoa Toxo-
Incubation period Variable, weeks to plasma gondii, found in the cat.
months.
Clinical features The toxoplasma, which
Occurrence and distribution Found in the develop from the oocysts, disperse to many
tropical and temperate regions of the world parts of the body including the CNS where
in areas where dogs and cats are kept as pets they form small inflammatory foci (pseudo-
or for hunting. Raccoons are progressively cysts). They result in surprisingly little
moving into urban areas where they pose a pathology to their host occasionally produ-
risk to children in particular. cing lymphadenopathy and a low-grade
fever, but congenital infection can result
Control and prevention Animal hookworms from an acutely infected mother. The infant
are prevented in the same way as human may have hepatosplenamegaly, corioretini-
infection with the wearing of adequate foot- tis or mental retardation and quite often
wear (Section 10.3). Efforts can be made to dies. Toxoplasmosis can also become reacti-
reduce cat and dog fouling by restraining vated in the immunocompromised (e.g.
them and keeping animals to designated in the HIV-infected individual), causing
parts of the village. Children should be pneumonia, myocarditis or fatal encephal-
taught to wash their hands before eating. itis.
The same methods as are used to reduce Recent evidence has suggested that
mosquito bites in lymphatic filariasis far from the pseudocysts causing little
(Section 15.7) are applicable for the dog pathology when they attach to the brain
and cat filarial infections; especially the of the non-neonate, they might produce
use of repellents and insecticide-treated some alteration in human response. Experi-
nets. ments in mice show that by the parasite
selectively attacking the brain, it disables the course of a meal should be strongly dis-
the animals response to the presence of a couraged. All meat should be properly
predator so making it more easily caught cooked and milk pasteurized. Childrens
and the parasite being transmitted. In the play areas, especially sandpits, should be
human, the effect is to prolong the reaction protected from cats.
time making the victim more likely to have a
road-traffic accident. Treatment Pyrimethamine, with or with-
out sulphonamides, can be used for treat-
Diagnosis can be made by a rise in specific ment.
IgM during the first 8 weeks, IgG over several
years or by lymph node biopsy. Surveillance In high-incidence areas, preg-
nant women can be asked questions on con-
Transmission Oocysts are passed in cat tact with cats or eating undercooked meat
faeces and if accidentally swallowed by during the antenatal visit.
humans they become infected. Children are
commonly infected when playing with pets,
or sand and soil in which cats defecate. 17.6 Brucellosis
Adults are more commonly infected from
swallowing pseudocysts in undercooked Organism is a Gram-negative bacillus, Bru-
meat (generally mutton or pork). Congenital cella melitensis, B. abortus, B. suis and
infection occurs when the mother becomes B. canis. B. melitensis causes the disease in
infected during the early course of her preg- goats that was first investigated in Malta
nancy. Oocysts can be inhaled or drunk in (Melita was the Roman name for the island).
contaminated water, and toxoplasma tachy- B. abortus, as its name implies, causes abor-
zoites are passed in cow and goat milk. tion in cattle. B. suis is an infection of pigs.
Both pigs and sheep are often infected with
B. melitensis and B. abortus. B. canis is
restricted to dogs.
Period of communicability Mothers can pass
The organism is killed by heating at
on infection to their fetus anytime during
608C for 10 min and by 1% phenol for
pregnancy, but the more serious disease
15 min. It survives well in milk and cream
results from infection in the first few
cheeses that have not fermented or gone
months. Oocysts remain viable in moist
hard. In places contaminated by the faeces
soil or water for at least a year and in raw
and urine of infected animals, survival can
meat until it is cooked.
be for months and even years, especially at
lower temperatures. With temperatures
Occurrence and distribution Exposure to
above 258C, survival time is reduced.
toxoplasmosis is common and widespread,
with up to 40% seropositive in some coun-
tries. Infection is also found in birds and Clinical features The severity and duration
other mammals including sheep, cattle, of the disease is very variable and may go
goats, pigs, chickens and rodents. All undiagnosed for a considerable period of
members of the cat family can produce time. Characteristically, there are intermit-
oocysts, often becoming infected from eating tent or irregular fevers (undulant fever) with
rodents or birds. generalized aches and pains. The patient is
unduly weak and tired, often retiring in the
Control and prevention is by personal hy- second half of the day. There may be depres-
giene especially hand-washing after touch- sion, a cough, lymphadenopathy and
ing cats. Cats should be banished at meal splenomegaly. Recovery may occur spon-
times and when food is being prepared. taneously, or the disease become chronic,
The habit of giving cats scraps of food during with the undulant pattern of fever and
278 Chapter 17
fatigue more pronounced. If not treated, this cattle paddocks, barns or shelters. The
can continue for 6 months to 1 year, after young can obtain infection through the
which 80% of patients fully recover. Abor- milk of their mothers.
tion is more frequent in women with the
disease. Control and prevention is by pasteurization
or boiling of cow and goat milk. Where pas-
Diagnosis is difficult, but isolation of the teurization is not a legal requirement,
organism from blood, bone marrow or urine people should be told of the risks of drinking
should be attempted. Serum agglutination raw milk and advised to boil it.
tests can be used, but a rise in titre is Anybody working with animals, espe-
required. cially those concerned with slaughter of
animals, or coming into contact with
Transmission Humans are infected by drink- products of abortion, should wear overalls
ing raw milk or milk produce. B. melitensis and gloves that are frequently washed and
is mainly spread by unpasteurized goats sterilized. Proper animal husbandry reduces
milk or the consumption of cream cheeses areas of contaminated pastureland that per-
prepared from it. B. abortus has less invasive petuates infection.
power and virulence when consumed in Where facilities permit, herds or flocks
cows milk and so asymptomatic infection can be rendered Brucella-free by diagnosis
from drinking cows milk can occur. In and slaughter of infected animals. A useful
people whose occupations bring them test for this purpose is the milk-ring test on
in close proximity to animals, infection cows milk. Haematoxylin-stained Brucella
can occur through the skin, probably via an antigen is added to a sample of cows milk
abrasion, the mucous membrane, the con- and if positive, a blue ring appears at the
junctiva or as an aerosol through the respira- interface. By removing infected animals
tory tract. Such persons as farmers, from a herd and preventing them from
shepherd, goat herds, vets and abattoir coming into contact with others, whole
workers are at greater risk. Animal handlers areas of land, and even complete countries,
can contract the much rarer B. canis infec- have been made Brucella-free. This is a large
tion from dogs. and expensive undertaking and beyond the
means of many developing countries. An
Incubation period is 560 days, but may be alternative is to vaccinate herds. The live,
up to 7 months. attenuated vaccine Rev-1 or recombinant
RB51 can be given to calves at 68 months.
Vaccination can also be given to adult
animals, but should not be administered if
from person to person.
an eradication programme is envisaged as it
then becomes impossible to tell whether an
Occurrence and distribution The disease is animal is infected or not.
mainly one of animals, resulting in eco-
nomic losses to the society and ill health
to those involved in looking after animals. Treatment is with doxycycline 100 mg every
Brucellosis is common in South and Central 12 h combined with either rifampicin
America, Africa, the Mediterranean, South, 600 mg daily, or streptomycin 1 g daily, for
Southwest and Central Asia. It is often not 6 weeks.
recognized, being found in a large number of
animals if looked for. In Sudan and Nigeria, Surveillance of cattle using the milk-ring test
60% of cattle were found to be infected. (see above). Brucellosis is a notifiable dis-
Cattle become infected from eating pla- ease in countries in which it has been elim-
centae, licking a dead fetus or close contact inated, such as in northern Europe, USA and
with contaminated surroundings, such as Japan.
17.7 Anthrax symptoms of varying severity. The patient

feels unwell although the temperature is
Organism Bacillus anthracis is a rod-shaped normal or only slightly raised. A high tem-
organism occurring in pairs or chains and perature or weak pulse is a serious sign, gen-
staining positively with Grams stain. In erally indicating pulmonary disease, which
the vegetative state in the animal or where results from the inhalation of a large dose of
there is a low oxygen content, the bacillus is spores. Illness sets in rapidly with cough,
surrounded by a capsule. If the dead dyspnoea and cyanosis. Lymph nodes en-
animals tissues become exposed to the air large and there is splenomegaly. This passes
or the organism is cultured aerobically, then into a stage of cardiovascular collapse and
spores develop, which appear as round- the patient is dead within 23 days.
filling defects in the stained rods. Intestinal anthrax is another uncom-
The vegetative form is killed by heat at mon, but severe form of the disease resulting
558C for 1 h, or if the carcass is not opened, from people eating infected meat. The pri-
putrefaction will raise the internal tempera- mary lesion occurs in the intestines and the
ture sufficiently (308C for 80 h) to render it massive oedema that results produces intes-
free of organisms. However, if it is butchered tinal obstruction as well as systemic symp-
or a post-mortem performed, then exposure toms. However, cutaneous anthrax is the
to the air encourages the development of commonest form even in people who
highly resistant spores, which are one of butcher and subsequently eat an animal
the most persistent forms of life known. that has died from anthrax.
They have survived 1608C for 1 h and
788C despite thawing and re-freezing, Diagnosis is made by examination of the
while in pastures they have been found fluid from the vesicle in a person who gives
viable after 12 years and possibly up to 60 a history of contact with an animal that re-
years. cently died. A smear is made on to two
slides, one being stained by Gram and the
Clinical features Essentially an infection of other fixed by heat and stained with methyl-
cattle, anthrax ranks with rabies and plague ene blue or Giemsa. The first shows Gram-
as a much feared and fatal disease. Infection positive rods and the second demonstrates
commences with a small papule at the site of the red capsule surrounding the blue bacilli.
inoculation. By the second day, a ring of This finding can be confirmed by culture on
vesicles surrounds the lesion, which are at selective media.
first clear, but then become blood-stained.
The central papule then ulcerates and en- Transmission Anthrax spores are ingested or
larges to form a depressed dark eschar, become accidentally inoculated through the
which increases in size and darkens to the skin, such as by thistle scratches around the
black coal colour that gives the disease its muzzle or legs of an animal close grazing in
name (anthrax is coal in Greek). Pus is never an infected pasture. Biting flies have also
present despite the development of oedema been incriminated. The spores germinate
around the lesion. The oedema is extensive into the vegetative form, which rapidly in-
and may cause respiratory embarrassment if vades, increasing in virulence. A local
around the neck. The associated lymph lesion grows at the point of inoculation and
nodes are often enlarged, but must be left to extensive oedema develops around it. The
resolve spontaneously. The primary lesion capsulated bacilli produces a lethal factor,
commonly occurs on the head or face, while which causes anoxic hypertension or car-
the neck and forearm are also often affected. diac collapse, resulting in sudden death of
Surprisingly, the fingers are rarely in- the animal. After death, the animal appears
volved. black from tarry blood that is slow to clot.
As well as the primary lesion and its People are infected by contact with the
surrounding oedema, there are systemic deceased animal, either in butchering and
280 Chapter 17
handling of the infected meat, or at a place year at the same site, so-called anthrax
far removed from the death of the animal districts. Hot, moist areas are particularly
from spores in its hide, hair or bones. liable to offer the right conditions for con-
tinuous sporulation and germination,
Incubation period is less than 7 days, with as leading to a steady infectious state through-
short as only 2 days in the rapidly fatal pul- out the year. In contrast, hot arid areas en-
monary form. courage spore formation and when the
vegetation dries out, close grazing brings
the animal into proximity with the spores
Period of communicability Not transmitted in the dust, so a dry season outbreak is
from person to person. more common. This can be anticipated
and cattle vaccinated prior to the anthrax
Occurrence and distribution The disease season.
commonly affects cattle, sheep, goats and Anthrax is an occupational disease in
horses, but has occurred in dogs and cats. those persons who deal with hides, hair
It is probably widespread in the wild and (including wool) and bones of animals. The
has been found in elephants, hippopot- spores can persist almost indefinitely in
amuses and on the claws and beaks of vul- these animal remains and when tested are
tures and other scavenger birds. Widespread found to be present in a large proportion.
in the bovine populations of the world, its Pasturalists particularly will not waste an
persistence in the environment and in the animal that dies and taking off its skin and
produce of cattle makes it an ever-present leaving the bones to dry in the sun encour-
threat both in the developing and developed ages formation of spores which remain with
world. It is a particular problem in Africa, these products when they are shipped all
Southwest Asia, Russia, South and Central over the world. It is an impossible task to
America. identify these infected animal products and
because of the high proportion involved, an
Control and prevention is difficult due to the uneconomical process to destroy them.
persistence of the organism in the environ- Quite surprisingly, people who handle
ment, but once an outbreak starts, it should infected hides and products only rarely de-
be possible to bring it to an end by vigorous velop anthrax, but they should, of course, be
control of animals and their slaughter. No warned and provided with facilities to be
animal that dies from anthrax should be examined and treated. Protective clothing
allowed to be butchered and sold for meat. should be provided and a ventilation system
Its hide and bones are also infectious, so to remove spores from the air when
should be deep buried with lime or burnt. unpacking, beating or a similar process
Anthrax is a common disease in pasturalists. occurs. Many industrial processes disinfect
For fuel, they often conserve dried cow the animal products, but where this does not
dung, which also makes an ideal material occur, sterilization can be introduced. With
to incinerate the carcass as it burns slowly persons at increased risk of developing an-
but continuously. thrax, vaccination can be offered. The vac-
The animal should not be cut open to cine is from a sterile filtrate of B. anthracis
obtain specimens or perform autopsy, but and is given in 0.5 ml doses at 6 weeks after
cutting off an ear is quite sufficient for diag- the initial dose, then 6 months and there-
nostic purposes. after at annual intervals. Modified anthrax
Once anthrax is recognized, then all can occur in the vaccinated.
animals should be vaccinated with a live,
attenuated vaccine. Due to the persistence Treatment is with penicillin to which the
of the organism in the soil, especially at a organism is very sensitive. Benzylpenicillin
site where an infected animal has been 4 million IU every 46 h for 7 days or if still
buried, anthrax is likely to recur year after available, procaine penicillin 1 mega unit
daily for 3 days can be used. No local treat- After this time, serological tests or animal
ment is required and surgical removal of the inoculation can be used, whereas Leptospira
eschar or incision of oedema only leads to may be found in the urine from the third
unpleasant scarring and development of in- week onwards. Culture of the organism can
tractable sinuses. Ciprofloxacin or doxycy- take up to 1 month.
cline can be used for respiratory and
intestinal cases. Supportive measures need Transmission The Leptospira enters the skin
to be given for shock and tracheostomy may of humans through minor abrasions or
be required when there is severe oedema of mucous membranes, although it does
the neck. appear to be able to enter unbroken skin as
well. Infection results from exposure to con-
Surveillance Anthrax is a notifiable disease taminated moist areas, such as swimming in
in many countries. Where no animal source canals, or walking barefoot over damp rat-
can be shown, then bioterrorism should be infested soil. A direct rat bite can transmit
considered (Section 18.5). the disease, as also an aerosol of contamin-
ated fluid or ingestion of contaminated food.
Other animals can become infected
with different serovars: cattle and water buf-
17.8 Leptospirosis
falo with hardjo, dogs with canicola and
pigs with pomana. These domestic animals
Organism Leptospira interrogans with a subsequently excrete Leptospira in their
large number of serovars, the most import- urine, contaminating the surroundings.
ant of which is icterohaemorrhagiae. It is
passed in rats urine and can contaminate Incubation period is 419 days, usually 10
any area that they frequent. For the survival days.
of the organism, there must be moisture,
such as a canal or sewer, or else in damp Period of communicability Leptospira are ex-
soil, the washings of abattoirs or similar creted in the urine for several months, but
conditions. The pH of the soil or water is person-to-person spread is rare.
important and the Leptospira cannot survive
in an acid environment. Leptospirosis is, Occurrence and distribution Where rats are
therefore, commoner in places where the common and conditions are favourable, the
soil is alkaline. Salt water and chlorine solu- infection is widespread. In many areas
tions rapidly kill the organism. surveyed, Leptospira antibodies have been
found in a large percentage of the popula-
Clinical features Commencing with fever, tion, endemic in the community with the
malaise, vomiting and myalgia, jaundice occasional severe case. It is common in the
subsequently develops and there may be tropics particularly where the soil is alkaline
haemorrhages into the skin, mucous mem- or irrigation is used for agriculture. Infection
branes and internal organs. The disease is, therefore, common in rice paddy areas
may progress to a more serious form with and sugarcane estates. This association of
liver failure, renal failure or meningitis. the disease with certain occupations is help-
However, many people only have mild in- ful in making the diagnosis. Such occupa-
fections and the vast majority do not exhibit tions as mine workers, farmers, canal
any symptoms at all. In endemic areas, cleaners, sewer workers, people employed
children are probably most commonly in the cleaning and preparation of fish or in
infected. abattoirs, are at greater risk.
Flooding can widen the area of contam-
Diagnosis is by finding the motile organism ination leading to outbreaks in people not
by dark field illumination in a wet blood normally at risk. Disasters and any alteration
film during the first week of the disease. in conditions that leads to an increase in the
282 Chapter 17
rat population will have a similar, but more 17.9 Lassa Fever
long-term effect.
Leptospirosis is a very widespread zoo- Organism Lassavirus is an arenavirus.
notic infection of animals, endemic in many
rodents, especially rats. The organism has Clinical features There is a gradual onset
been found in a variety of other animals, with fever, malaise, sore throat, cough,
opossums, mongooses, skunks, hedgehogs, vomiting, diarrhoea and general aches and
squirrels, rabbits and dogs, to name but a pains. By the second week, lymphadenop-
few, but the two domestic rats Rattus rattus athy, pharyngitis and a maculo-papular rash
and R. norvegicus are by far and away the on the face or body develops. In severe cases,
most important reservoirs. pleural effusion, encephalopathy, cardiac
and renal failures can occur with a mortality
Control and prevention is the avoidance of of 1520%.
areas contaminated with rat and animal In endemic areas, 80% of cases are mild
urine, often a difficult thing to achieve. Vari- or asymptomatic so that serological investi-
ous measures are: gation will find a large number of people
with past history of infection.
. the reduction of rats by extermination and
protection of buildings, especially those Diagnosis is often made on clinical criteria
used for preparing meat, fish and housing once the first case has been identified, with,
domestic animals (rat control in Box 16.1); in particular, inflammation of the throat and
. burning of sugarcane fields after harvest white tonsillar patches. Confirmatory diag-
and the drying out of rice fields; nosis is made by testing IgM or IgG in urine,
. wearing of protective clothing to reduce blood or throat washings, with ELISA, PCR
abrasions and contamination; or IFA, using extreme care.
. avoiding canals, lakes and bodies of water
known to be infected; Transmission is primarily through contact
. controlling the number of dogs; with the excreta (urine and faeces) of
. providing proper pens with drainage for infected rodents, deposited on floors, beds
domestic animals so that urine does not or other surfaces, or through rat contamin-
collect and make the surroundings ation of food or water. The main reservoir
sodden; is the multi-mammate or grey rat, M. nata-
. wash down food premises with a solution lensis. This is probably the method of spread
of chlorine or salt water. in the endemic area resulting in a large
number of asymptomatic cases. However,
Vaccination of persons at risk has been in the severe case, all human body fluids
achieved in some countries using the spe- are highly infectious so that secondary
cific serovar. Doxycycline prophylaxis can spread commonly occurs through contact
be used where short-term exposure is with blood, urine, throat secretions and the
expected (e.g. in troops). aerosol produced by a coughing bout. The
semen remains infectious for a considerable
Treatment is with benzylpenicillin 2 mil- period of time so transmission via the sexual
lion IU every 6 h or doxycycline 100 mg for route can occur long after the person has
7 days, preferably within the first week of recovered from their clinical illness.
the illness.
Surveillance Leptospirosis is a notifiable
disease in many developed countries. Period of communicability All body fluids
Where outbreaks occur, the cause should are infectious from the start of the illness
be investigated and specific control meas- and up to 9 weeks for urine and 3 months
ures instituted. for semen.
Occurrence and distribution Lassa fever is sodium hypochlorite, 0.5% phenol with
found in West and Central Africa including a detergent, autoclaving or boiling;
the countries of Guinea, Sierra Leone, Li- . extreme precautions with any oral secre-
beria, Nigeria and Central African Republic, tions, blood, faeces and urine. Blood must
but serological testing has found evidence of be handled with the utmost precaution
infection in Senegal, Mali, Guinea Bissau using, as a minimum, holeless rubber
and the Congo. gloves. Faeces and urine should be placed
All ages and both sexes are susceptible, in plastic bags, which are boiled or
but pregnant women have a severe infec- burnt;
tion with high mortality and loss of the . terminal disinfection with formaldehyde
fetus. fumigation to all articles used by the pa-
tient.
Control and prevention is by control of
the rats and careful isolation of patients. Treatment is with ribavirin intravenously
M. natalensis lives in close proximity to for 10 days within the first 6 days of illness.
humans in the home, fields where people
tend their crops, and in mines and similar Surveillance All close contacts of a case
industrial sites. Rats should be controlled should be identified and followed up for 3
(see Box 16.1) and prevented from entering weeks with twice daily temperature, and
the home. Food and drinking water should hospitalized if it becomes more than
be protected with covers and a state of 38.38C. With air travel, it is possible that an
cleanliness observed to minimize rat excreta incubating case may travel to another coun-
contamination. try before showing symptoms, so if there is
All cases must be hospitalized and: any indication, such as coming from an
infected area, then the person should be ad-
. rigorous isolation of the patient by the mitted to hospital with strict barrier nursing
most secure means possible; procedures. Any known or suspected case
. careful sterilization of syringes, needles should be reported to WHO and neighbour-
and all re-used equipment with 0.5% ing countries.
18
New and Potential Diseases
Biology is not static evolutionary forces eously in English and French by the WHO
will always look for opportunities to exploit and available on www.who.int/wer/2004/
new situations and no more so than in the en/ where back copies can be found. A
field of communicable diseases. Humans choice of the year in the address is available
have always waged a continuing war against to get information, or if the latest copy is
organisms that attack them and although required, it can be obtained by subscription
many might now be prevented, new organ- or a week later on the Internet. Also avail-
isms will seek to exploit any weakness in able from the Centres for Disease Control
our defences. This chapter, therefore, looks (CDC) is the Journal of Emerging Infectious
at new and emergent diseases, plus what Diseases on www.cdc.gov/ncidod/eid/past-
might be termed potential diseases infec- con.htm in which research and general art-
tions that could attack us, but have not icles are published.
shown any sign of doing so yet.
The term conflict has been used above
not only because our battle with parasitic
organisms is like an arms race, but also 18.1 The Animal Connection
because the horror of using infectious organ-
isms by terrorist organizations in a purpose- In the 1970s, it seemed as though the battle
ful way to attack people is now a possibility. against the communicable diseases was
This will probably be with organisms that won, we had all the weapons we needed to
are known to us, but in a way that would control most of them, all that was required
ensure that they are particularly potent. The was to have sufficient resources to combat
last section of this chapter, therefore, looks the diseases in the developing world. Small-
at possible bioterrorist-induced diseases. pox had been eradicated and the develop-
This chapter more than any other in this ment of vaccines promised a similar fate for
book will require constant updating, which polio and other immunizable diseases, but
can be done with much useful information then in 1981, there was a rude shock.
now freely available on the Internet. The In June 1981, CDC in the USA reported
best source of information on epidemics five cases of Pneumocystis carinii pneumo-
and new diseases, with good updates on nia. In the following month, 15 more cases of
major health problems, is the Weekly Epi- this normally rare disease were reported as
demiological Record, published simultan- well as 26 cases of Kaposis sarcoma, an
284
New and Potential Diseases 285
unusual tumour. The common feature was found in the Fore people of Papua New
that all these cases were in homosexual men. Guinea who traditionally eat the brains of
By the end of 1981, acquired immune defi- the recently dead in the belief that they
ciency syndrome (AIDS) as it was called, will obtain the wisdom and prowess of
was also being reported from countries in their ancestors.
Europe. In Belgium and France, an AIDS- The TSEs have been shown to be due to
like illness was observed amongst people a new kind of organism, a self-replicating
originating from Africa. These observations protein called a prion, which produces a
led to investigations in Rwanda and Zaire clinical picture of depression in humans
(now Congo) where many AIDS patients followed by organic brain disease, including
were found. At the same time, an aggressive cerebella ataxia, cortical blindness, local-
form of Kaposis sarcoma was reported from ized weakness and progressive intellectual
Zambia and a new disease, called slim dis- deterioration. Speech is lost, swallowing be-
ease, described in Uganda. These were all comes difficult and a rigidity of limbs de-
found to be manifestations of AIDS. The Af- velops as the patient sinks further into a
rican infection was transmitted heterosexu- hopeless state of debility and death. Unfor-
ally, starting its relentless course that has tunately, it is difficult to confirm the diagno-
continued unabated until the present time. sis of vCJD (tonsillar biopsy and magnetic
The appearance of HIV infection alerted resonance scans are useful) until after
the world to new communicable diseases, death, indicating that there had been 142
several more (e.g. Lassa, Ebola and Marburg), cases by the end of 2003. This fortunately
of which have appeared in the last few years. suggests that the epidemic will not be as
Where had they come from and why were large as was feared, and as all offal-based
they appearing at this time? The first clue ruminant feeds were banned in Europe in
came with the discovery of a virtually iden- 1994, there should be few if any more
tical retrovirus to HIV in simian monkeys cases.
called simian immunovirus (SIV), suggest- While the public health profession was
ing that HIV originated from a monkey recovering from BSE and vCJD, another new
source. Then in 1986, a disease appeared in communicable disease, severe acute respira-
cattle in England called bovine spongiform tory syndrome (SARS) was reported from
encephalopathy (BSE), which was shown to Vietnam in February 2003. A businessman
be due to cattle being fed the remains of who had been travelling in China was admit-
sheep in their feed, some of which had the ted to hospital in Hanoi with a history of
similar sheep disease called scrapie. This high fever, cough and difficulty in
had not been transmitted from sheep before, breathing. His condition worsened, so he
so somehow the organism had crossed the requested to be transferred to Hong Kong,
species barrier and if this had happened where despite ventilatory support, he died.
from sheep to cattle, then why not from cattle In the hospital in Hanoi, several health care
to humans when they ate infected meat? workers contracted a similar illness and the
Sure enough the first case of a new variant attending doctor and a nurse died. Search
CreutzfeldtJakob disease (vCJD) appeared was made for the organism, which at first
linking this condition to the consumption was thought to be a new strain of influenza,
of beef. Since BSE had a 45-year incubation but subsequently was identified as a corona-
period, the potential for human infection virus. An incubation period of 114 days,
was enormous and there was much specula- but more commonly 35 days and period of
tion as to what would happen. communicability of 314 days from the start
CJD is one of the group of transmissible of symptoms was subsequently calculated.
spongiform encephalopathies (TSEs) Fortunately, the household secondary
which, as well as BSE in cattle and scrapie attack rate was between 6% and 15% in
in sheep, is also found in other animals such Singapore and Hong Kong, especially low
as mink, elk and North American mule deer. if the initial case was a healthcare worker.
The only other human disease is kuru, This contrasted with hospitals, especially if
286 Chapter 18
their barrier nursing was deficient, which droplets rather than aerosol, and possibly
were found to be potent sources of transmis- also via sewage contamination in one area
sion. of Hong Kong. Several of these animals are
Tracing the case back, it was discovered regarded as delicacies and kept in cages so it
that there had been a number of cases of a seems quite possible that either of these
severe and highly contagious pneumonia in methods could have been how the food
Guandong Province (Canton), southern handlers were infected. After the main epi-
China, in which one in 30 had died. The demic had finished, a new case was found to
attending specialist travelled to Hong Kong be strongly associated with the masked palm
for a wedding where in the early stages of the civet; hence, it seems likely that this could
illness, he himself infected all the people in have been how the epidemic started.
a lift in the hotel in which he was staying. Although SARS has declined to negli-
One of these persons was the case that came gible limits, its re-appearance must always
to Hanoi, another was a person from Singa- be considered. It has been suggested that a
pore and the third a lady returning to her clustering of pneumonia cases might be an
home in Toronto, Canada. Hong Kong, early indicator, while persons of an older
southern China, Singapore, Vietnam and age are more likely to transmit infection.
Canada then became the centres of epidem- While there is no cause to restrict travel,
ics, which demanded strict quarantine suspect cases are more likely to come from
measures to contain them. After draconian the southern regions of China where there
measures, especially in China, the last case have subsequently been three cases (up to
recovered at the end of July 2003. By that March 2004). Another case came from
time, there had been 8422 cases and 916 Henan Province in central China.
deaths. The so-called Asian flu epidemic of
Coming back to the original question of 1957 was found to have originated in
what was the link between the three epidem- chickens in Guandong province of southern
ics HIV, BSE/vCJD and SARS it seems China, followed in 1968 by the Hong Kong
likely that the organism, originally in influenza epidemic, which also originated
animals had crossed the species barrier from the same area. Although the 1918 epi-
into humans. HIV from simian monkeys, demic was termed Spanish flu, it is thought
BSE from scrapie-infected sheep and subse- that this too might have started originally in
quently via beef to humans, while SARS southern China. The world waits in dread
possibly also had an animal connection. for the next major epidemic of influenza,
Southern China enjoys a culinary custom possibly of a major antigenic shift (see
of eating almost any kind of animal, often Section 13.3), will it also originate here?
held in cages or fish tanks, until required for There have been pandemics in 1889, 1918,
the table. Such is the close proximity of 1957, 1968 and 1977 and the next one seems
people to all these animals and the general long overdue!
poor state of hygiene that all methods of A recent cause for concern that a major
transmission are possible. As well as the influenza epidemic might be starting was
respiratory route, the SARS virus was the appearance of avian influenza H5N1 in
found to be excreted in the faeces and urine January 2004. This is an infection predomin-
of patients, possibly up to 23 days after antly of chickens and ducks, but can also
symptoms first started. The original cases occur in pigs. It is highly infectious and
in southern China were in food handlers, results in an almost 100% mortality of do-
66 of whom were found to have antibodies, mestic fowl. The infection is probably main-
while of the animals tested masked palm tained in wild waterfowl, sea birds and
civets, raccoon-dogs, ferret badgers, cyno- shore birds and can be spread over long dis-
molgus macaques, fruit bats, snakes and tances when they migrate. However, the
wild pigs were all found to be positive. transport of birds, contaminated clothing
Transmission in humans was through close and equipment are probably more likely
human contact as the infection was in large causes, once infection in a fowl population
has started. Bird droppings are highly infec- . peripheral distribution of the rash
tious, so humans coming into contact with (including soles and palms);
them or sick birds are at risk of infection. An . lesions pass through the same stages at the
outbreak occurred in Hong Kong in 1997 same time;
with 18 human cases, of which six died. . fever intensifies as the rash progresses to
The same virus was identified in fowls in the pustular stage;
2002, resulting in a mass slaughter of . lesions are deeply seated flat-topped and
chickens, but despite this action, there centrally depressed.
were four more human cases (two of which
died) in 2003. In 2004, there was a more These features should be compared with
serious epidemic in Thailand and Vietnam chickenpox (Section 12.1).
that spread to domestic fowls in other coun- Smallpox vaccination (vaccinia virus)
tries in Southeast and East Asia (Cambodia, also protects against monkey pox, so the
China, Indonesia, Japan, Laos and South waning level of vaccination poses the theor-
Korea) with 34 human cases and 23 deaths. etical possibility of it spreading. However,
The main concern was that the avian the well-defined distribution, and the low
flu could acquire genes from the human in- secondary attack rate in close contacts,
fluenza organism and produce a potent makes it unlikely to develop into such a
infection that nobody would have any serious disease and smallpox vaccination
resistance to. Fortunately, this epidemic can be used to prevent it.
subsequently declined, but influenza There are also other animal pox virus
remains the greatest threat of any emergent diseases which have infected or could infect
infection. humans. Examples are cowpox, camelpox,
tanapox, yabapox, buffalopox and goatpox.
There is very little evidence to suggest that
18.2 The Pox Diseases any of these diseases can cause an infection
in people that is likely to be spread from one
The reason for including smallpox in the person to another to any marked extent, but
first edition was that there was a possibility their importance is to recognize that they
that like the diseases already mentioned, can occur and to differentiate them from
one of the animal pox diseases could smallpox.
become serious in humans. Smallpox vac-
cination probably lasts for 10 years, possibly
up to 30 years, but since smallpox vaccin-
ation was stopped in 1979, there is a de- 18.3 Nipah and the Lyssa Viruses
creasing number of people with any
remaining immunity. In 1999, a severe encephalitic illness
Monkey pox is a rare zoonosis, signifi- occurred in Nipah, Malaysia, caused by
cant because it produces a disease similar to what has now become called Nipah virus,
smallpox, localized to tropical rain forest closely related to Hendra virus, first
areas of west and central Africa. Most cases reported in the town of this name in
have been reported from Congo (formerly Australia. They are members of the virus
Zaire). Although it is a disease of monkeys, family Paramyxoviridae. The illness com-
it occasionally affects humans. It has a commences with fever and muscle pains,
parable casefatality rate to smallpox al- then progresses to encephalitis with a
though the secondary attack rate is much 50% mortality. The incubation period is
lower (15%). 418 days. Another new virus disease
The characteristics of smallpox and called Manangle was discovered in 1997
monkey pox are: also originating from pigs, but as it consisted
of only two cases of an influenza-like
. clear-cut prodromal period of sudden illness and rash, little notice was taken
onset of fever, headache and prostration; of it.
288 Chapter 18
Nipah is a zoonosis of pigs with the The number of arbovirus infections

possible involvement of dogs and cats also, in the world is enormous (Chapter 19) and
and transmission probably occurs from new ones are likely to appear at any time.
close contact with body fluids or tissues of Although they are mainly transmitted by
the animal. However, the risk of transmis- mosquitoes or ticks, it is likely that the res-
sion to humans is low, although all precau- ervoir will be in birds or mammals, as
tions, with the wearing of gowns and gloves, new-species adaptations, similar to the dis-
should be taken when handling animals. eases mentioned above, seems to be how
Hendra is a similarly transmitted disease of new diseases generally arise in the human
horses. Epidemics of Nipah occurred in population.
Malaysia in 19981999 (265 cases, 105
deaths), Singapore in 1999 (11 cases, one
death) and Bangladesh in 2001 (30 cases, 18.5 Bioterrorism
18 deaths).
The Nipah, Hendra and Manangle vir- The idea of using biological substances for
uses are found in insectivorous and fruit- warfare is not new. In 1347, when the
eating bats (including flying foxes) that are Mongols laid siege to Caffa (now part of the
not made ill by them. Infected bat colonies Ukraine), they catapulted the bodies of
have so far been found in Malaysia, Indo- plague victims over the walls at the Genoese
nesia, the Philippines, Australia and some defenders. Escaping in their ships, the sol-
of the Pacific Islands, but how the infection diers accidentally carried the bacillus back
is transmitted from the bats to either pigs or with them to Mediterranean ports, so
horses is not known. Also, examination starting the devastating epidemics of plague
of bats has shown a number of lyssa viruses that became known as the Black Death.
(related to rabies), including Australian bat Since then, there has been such a horror of
lyssavirus and a newly discovered candi- biological warfare that treaties and under-
date called Tioman. So far, no human illness standings, even in the midst of world wars,
has been reported, but the place of the bat as has prevented their use to any large extent.
a reservoir of disease is becoming ever more Sadly, unscrupulous persons have resorted
important and greater precautions may need to these methods to terrorize people in this
to be taken in places where they are modern age, raising the question as to what
common, for fear of a new infection origin- they are likely to use and with what results?
ating from this source. The most highly infectious disease of
humans is smallpox and this would be the
disease of choice if one wanted to produce
the most devastating effect. Of the last two
18.4 Arboviruses remaining colonies of variola virus left in the
world, one is in the USA and the other is in
The arboviruses (Section 15.2) have a pro- Russia and were due to be destroyed in 2002,
pensity for producing new diseases un- but this has now been changed to regular
matched by any other organism. At quite inspections. So unless the virus was stolen
regular intervals, new arboviral diseases or in any other way obtained from either of
appear or those normally restricted to small these sources, the risk is minimal. Even if an
areas of the world spread to new areas or outbreak did occur, then the means to con-
become more important as human diseases. trol it by vaccination is readily available and
Examples are West Nile virus, which has it would then just depend upon the time it
appeared for the first time in North America, took to produce enough vaccine and vaccin-
Rift Valley fever, which was normally con- ate people. As mentioned above, anyone
fined to Africa, but has now spread to Asia born before 1979 is likely to have been vac-
(Section 15.2) and CrimeaCongo disease, cinated and even though their immunity
which now has a worldwide distribution would have waned, they would probably
(Section 16.9.2). have a milder form of the disease.
Plague is a more likely contender as the deadly weapon, the organism needs to be
bacillus is readily obtainable and as shown inhaled or swallowed without first touching
above, can be spread with devastating the skin, as in natural infections where
results. However, it is an infection that is people consume meat from an animal that
well known and reasonably easy to contain has died of anthrax, nearly all of them
within well-circumscribed areas, as men- develop cutaneous rather than intestinal
tioned in Section 16.1. To make an effective disease. For it to be effective, anthrax
weapon, the bacillus would need to be for- would, therefore, need to be administered
mulated in such a way that it was spread by as a fine powder or in an aerosol.
the respiratory route, which without first Probably the easiest biological sub-
passage through a human as septicaemic or stance to use as a terrorist weapon is botuli-
pneumonic plague might not be possible. A num toxin. The toxin is produced by
vaccine is available which could be utilized Clostridium botulinum in foods that have
in an emergency and treatment is effective if been poorly processed in any preserving
given soon after symptoms develop. method, particularly home preservation of
Similar to plague and easy to obtain fruit and vegetables that have not been held
would be Francisella tularensis, the organ- at a high enough temperature for sufficient
ism that produces the disease tularaemia. length of time. When these foods are eaten,
Found in the northern part of the world the patient, after a brief incubation period of
(Russia, China and the USA), it is transmit- 1236 h, develops a dry mouth followed by
ted by almost every conceivable method blurring of vision, difficulty in swallowing,
from the bites of ticks, mosquitoes and the weakness and in the severe case a flaccid
biting fly Chrysops, in contaminated water paralysis, with mortality of about 10%. It
or uncooked meat, by the inhalation of dust would, therefore, be quite easy to produce
and hay from contaminated areas and the toxin and introduce it as a foodstuff to
through handling small animals, either by the unsuspecting recipients or administer it
their bite or contact with their tissues. It as an aerosol in a direct attack. So if there is
presents as an ulcer at the site of introduc- no obvious source of botulism in a food
tion of the organism, with lymphadenop- source, then bioterrorism should be sus-
athy, then spreads to many sites in the pected.
body including the lung. It is this respiratory Any case of botulism should be
form, like pneumonic plague, that would reported to the local medical authority
make it a possible weapon. Sprayed in an responsible and the suspect food item sent
aerosol, the cause would probably go unrec- for analysis prior to destruction by pro-
ognized. Fortunately, tularaemia can be longed boiling or incineration. The patient
treated with streptomycin or gentamicin should be purged, the stomach washed out
and a vaccine has been used in Russia, so and if seriously ill, given polyvalent botuli-
providing the cause could be identified rea- num antitoxin. The usual cause of death is
sonably quickly, preventive action could be respiratory failure; so facilities, including
taken. intubation, should be made ready in case of
Anthrax is probably the most likely can- need. Everybody else who might have eaten
didate and was used in the USA in 2001 in from the same food source must be con-
an attempt to target certain individuals tacted and observed.
through the postal system. A special formu- With any biological weapon, it is the
lation, probably obtained illegally from a preparation and means of administration
biological warfare establishment was used, that are the key factors, so unless the terror-
and this would be necessary if it was to be ist has resource to laboratories and some
tried again. Cutaneous anthrax is generally a sophisticated equipment, it is likely to be
non-fatal disease, readily responding to by theft or purchase that substances will
treatment (Section 17.7) and the commonest be obtained. Hopefully, these are being care-
form of the disease. For anthrax to be a fully guarded against.
19
List of Communicable Diseases
Communicable diseases are listed in alpha- ation, vaccination and the wearing of gloves
betical order by the most commonly used and protective clothing (An), testing of
name. Other names will be found in the donors and treatment of blood for transfu-
index. Diseases printed in bold are covered sion (Bl), chemotherapy where this is used
in the text. as a method of control (Ch), food hygiene,
Incubation periods are the usual range, cooking and refrigeration (Fo), personal hy-
but exceptions to these limits do occur. giene (Hy), vaccination/immunization (Im),
Agents are: arboviruses (A), bacteria (B), sterilization of needles, instruments and
ectoparasites (E), fungi (F), helminths (but blood giving sets (Ne), rat control (Ra), sani-
not nematodes) (H), nematodes (N), prion tation (Sa), water supply (Wa), vector con-
(O), protozoa (P), rickettsiae (R), spiro- trol (Vc) and methods for controlling STIs
chaetes (S), toxins (T) and other viruses (Xe).
(V). Methods of control are: animal elimin-
Means of transmission
Disease Clinical features (agent) (control method) Incubation period
Absettarov Fever (A) Ixodid ticks (Vc)

Acanthamoebiasis Granulomatous amoebic Through skin lesion or Weeks
encephalitis (P) conjunctiva
Actinomycosis Sulphur-granule lesions in Oral-to-oral (dental Monthsyears
jaw, thorax or abdomen (F) hygiene)
Acute respiratory Fever, cough, pneumonia Airborne and oral (Ch, Im) 13 days
infections (B, V)
Aeromonas Diarrhoea, vomiting (B) Contaminated food or
water (Fo, Hy, Wa)
Alenquer Sand fly fever (A) Phlebotomus (Vc) 36 days
Amoebiasis Diarrhoea and systemic Faecal-contaminated water 24 weeks
abscesses (P) and food (Wa, Sa)
290
List of Communicable Diseases 291
(Continued )
Angiostrongylus Meningeal, CNS and Uncooked snails and slugs, 13 weeks

abdominal signs (N) rat reservoir (Fo, Ra)
Aniskiasis Intestinal abscess (N) Uncooked fish (Fo) Hours
Anthrax Skin, intestinal or respiratory Contact with infected 27 days
lesions (B) animal tissues (An, Ch)
Apeu Fever (A) Aedes and Culex, 312 days
mosquitoes, rodent
reservoir (Vc)
Apoi Encephalitis (A) Vector (unknown) 515 days
Armillifer Calcified nodules (E) Eating raw snakes or
snake-contaminated
water (Fo, Wa)
Ascaris (N), malnutrition, intestinal Ingestion of soil or food (Fo, 1020 days
symptoms Hy, Sa)
Aspergillosis Bronchial obstruction and Airborne from compost, hay Daysweeks
eosinophilia (F) or stored grain
Babesiosis Fever and haemolytic Ixodes ticks, blood 18 weeks

anaemia (P) transfusion (Vc, Bl)
Bacillary dysentery Diarrhoea with blood (B) Faecaloral, water, milk, 17 days
flies (Hy, Wa, Sa)
Balantidiasis Diarrhoea (P) Faecaloral, food, water Days
(pig reservoir) (Hy, Fo,
Wa)
Bangui Fever and rash (A) Vector (unknown) 45 days
Banzi Fever (A) Culex mosquito (Vc) 515 days
Barmah Forest Fever, arthritis (A) Culicine mosquito (Vc)
Bartonellosis Fever or skin sore (B) Lutzomyia sand flies (Vc, 1622 days
Bl)
Batai Fever (A) Culicine mosquito (Vc) 45 days
Bhanja Fever, encephalitis (A) Tick (Vc)
Blastomycosis Pneumonia, skin lesions (F) Airborne in spore-laden Weeksmonths
dust
Bluetongue Fever (A) Culicoides midge (Vc) 312 days
Botulism Paralysis (B, T) Preserved food (Fo) 1236 h
Brazilian purpuric fever Conjunctivitis, meningitis (B) Contact with conjunctival 13 days
discharges (Hy)
Brucellosis Undulant fever (B) Milk, cheese and contact 560 days
with animal fluids (An,
Fo)
Bunyamwera Fever (A) Aedes mosquito (Vc) 312 days
Burkitts L. Lymphoma (V) Associated with malaria
(Vc)
Buruli ulcer Skin and tissue loss (B) Inoculation of organism
possibly by aquatic
insect
Bussuquara Fever (A) Culicine mosquito (Vc) 515 days
Bwamba Fever and rash (A) Culicine mosquito (Vc) 312 days
California E. Encephalitis (A) Aedes mosquito (Vc) 515 days

Campylobacter Diarrhoea (B) Food, milk, water or contact 110 days
with animals (Fo, Wa)
Candidiasis Thrush (F) Contact with secretions 25 days
(Ch)
Candiru Fever (A) Phlebotamus sand fly (Vc) 36 days
Capillariasis, hepatic Hepatitis and eosinophilia (N) Uncooked liver (Fo) 34 weeks
Capillariasis, intestinal Malabsorption syndrome (N) Uncooked fish (Fo) Months
Capillariasis, pulmonary Pneumonitis (N) Ingestion of foods 34 weeks
contaminated by soil (Fo)
(continued...)
292 Chapter 19
(Continued )
Capnocytophaga Fever, meningitis (B) Dog bite, scratch or lick 15 days

(An)
Caraparu Fever (A) Culicine mosquito, rodent 312 days
reservoir (Vc)
Cat-scratch fever Fever, lymphadenitis (B) Cat scratch bite or lick (An) 314 days
Catu Fever (A) Culicine mosquito (Vc) 515 days
Central European Encephalitis (A) Ixodes tick or drinking raw 714 days
encephalitis milk (Fo, Im,Vc)
Chagas disease Carditis and megacolon (P) Reduviidae bug, blood 514 days
transfusion (An, Bo, Ra,
Vc)
Chagres Fever (A) Phlebotamus sand fly (Vc) 36 days
Chancroid Genital ulcer (B) Sexual contact (Ch, Xe) 314 days
Chandipura Fever (A) Lutzomyia sand fly (Vc) 16 days
Changuinola Fever (A) Phlebotamus sand fly (Vc) 36 days
Chickenpox Rash (V) Skin or airborne contact 23 weeks
Chikungunya Fever, rash, arthritis (A) Aedes mosquito, reservoir 312 days
in baboons and bats (Vc)
Cholera Watery diarrhoea (B) Faecal contamination of 15 days
water or food (Hy, Sa,
Wa)
Chromomycosis Skin growths (F) Penetrating wound, e.g. Months
splinter of wood
Clostridium difficile Diarrhoea, colitis (B, T) Faecaloral (Hy and 25 days
reduce antibiotic use)
Coccidioidomycosis Disseminated abscesses (F) Airborne from soil in 14 weeks
endemic areas (dust
control)
Cold, common Respiratory infection (V) Airborne droplets through 13 days
nose, conjunctiva or
swallowed (Hy)
Colorado tick Fever (A) Dermacentor tick, reservoir 45 days
in small mammals (Vc)
Congenital CNS and liver abnormalities From genital secretions or 312 weeks
cytomegalovirus (V) breast milk. Adults
infected by sexual
contact or blood
transfusion (Bl, Xe)
Conjunctivitis Sore eyes (B, V) Contact with eye 13 days
discharges, airborne,
flies (Hy, Sa, Wa)
Creeping eruptions Urticaria and eosinophilia (N) Soil contaminated by dog Weeks to months
and cat faeces (footwear,
An, Hy)
CreutzfeldtJakob Encephalopathy and Infected meat and tissue 45 years
disease paralysis (O) contact (Fo)
Crimean-Congo Haemorrhagic fever (A) Hyaloma ticks and body 112 days
haemorrhagic fever fluid contact with humans
and animals (Vc, An)
Cryptococcosis Meningitis and skin lesions Airborne from pigeon
(F) droppings? (An)
Cryptosporidiosis Diarrhoea (P) Faecaloral and from 112 days
animals and water (An,
Hy, Sa, Wa)
Cyclospora Diarrhoea (P) Water and fruit (Hy, Fo, Wa) 510 days
Cytomegalovirus infection Mononucleosis and Contact with body fluids 312 weeks
congenital CNS lesions (V) and congenital. Blood
transfusion or transplant.
(Bl, Xe)
(Continued )
Dakar bat Fever (A) Vector (unknown) 515 days
Dengue Haemorrhagic fever (A) Aedes mosquito (Vc) 315 days

Dermatophagoides Asthma (E) Inhaled dust mites (reduce
dust)
Dhori Fever (A) Tick vector (Vc) 312 days
Diphtheria Pharyngitis, cutaneous Airborne or skin contact 25 days

lesions (B) from case or carrier (Im)
Diphyllobothrium Macrocytic anaemia (H) Eating uncooked 36 weeks
freshwater fish (Fo, Sa)
Dipylidium Tapeworm (H) Swallowing infected flea 34 weeks
(An, Hy, Vc)
Dirofilariasis Pulmonary eosinophilia (N) Culicine mosquito (Vc) Weeks to months
Dugbe Fever (A) Tick vector (Vc) 45 days
Duvenhage Rabies-like illness (V) Animal saliva or bite (An)
Eastern equine E. Encephalitis (A) Aedes mosquito, bird and 515 days
rodent reservoir (Vc)
Ebola Haemorrhagic fever (V) Contact with body fluids or 221 days
tissues (barrier nurse)
Echinococcus Hydatid cysts (H) From dog via fur, licking or Months to years
contaminated food or
water (An, Hy, Fo, Wa)
Echinostoma Diarrhoea (H) Food (raw snails, fish or
freshwater plants) (Fo)
Edge Hill Fever, arthritis (A) Culicine mosquito (Vc)
Ehrlichiosis Fever (R) Ixodes and Amblyomma 13 weeks
ticks (Vc)
Encephalitis lethargica Fever, encephalitis (V) Airborne
Enteritis necroticans Gangrene of bowl (B) Uncooked pork and beef 612 h
(Fo)
Enterobius Anal pruritis (N) Faecaloral and in dust 26 weeks
(Hy)
Enteroviral carditis Fever and myocarditis in Faecaloral or airborne 35 days
neonates (V) (mucus or faecal
material) (Hy)
Entomophthoramycosis Granuloma in skin or nasal Organism found in soil and
passage (F) rotting vegetation
Epidemic haemorrhagic Conjunctivitis and Contact with eye 13 days
conjunctivitis conjunctival haemorrhages discharges, airborne and
(V) in water (Hy)
Epidemic kerato- Keratoconjunctivitis (V) Contact with eye 512 days
conjunctivitis discharges or shared
treatments (Hy)
Epidemic myalgia Fever and pain in chest or Faecaloral or airborne 35 days
abdomen (V) (Hy)
Erysipelas Cellulitis of tissue (B) Contamination of abraded 13 days
skin; flies (Hy, Sa)
Erythema infectiosum Rash, fetal damage (V) Airborne, congenital, blood 420 days
transfusion (Bl, Hy)
E. coli 0157 Haemorrhagic colitis (B) From uncooked beef, milk, 28 days
faecally contaminated
water or vegetables (Fo,
Hy, Wa)
Everglades Fever, encephalitis(A) Culicine mosquito (Vc) 515 days
Exanthem subitum Fever, rash (V) Salivary contact (Hy) 515 days
Fascioliasis Liver damage (H) Uncooked freshwater

plants (Fo)
(continued...)
294 Chapter 19
(Continued )
Fasciolopsis Intestinal ulceration (H) Uncooked freshwater 23 months

plants (Fo)
Filariasis, lymphatic Lymphoedema (N) Anopheline and culicine 1 year
mosquitoes (Ch, Vc)
Fish poisoning Vomiting and parasthesia (T) Eating toxic fish (Fo) 0.53 h
Food poisoning Diarrhoea and vomiting (B, T) Contaminated food (Fo,
Hy)
Staphylococci 16 h
Bacillus cereus 112 h
Clostridium perfringens 1224 h
Vibrio parahaemolyticus 1248 h
Fort Sherman Fever (A) Culicine mosquito (Vc)
Gan Gan Fever, arthritis (A) Culicine mosquito (Vc)

Gastrodiscoides Diarrhoea (H) Raw vegetables and water
plants (Fo)
Gastroenteritis Diarrhoea (B, V) Faecaloral, food, water 1272 h
and milk (Hy, Fo, Im, Sa,
Wa)
Germiston Fever, rash (A) Culicine mosquitoes (Vc) 515 days
Giardia Diarrhoea, bloating (P) Faecaloral, water and 325 days
food (Hy, Fo, Sa, Wa)
Gnathostoma Systemic abscess (N) Uncooked fish or poultry
(Fo)
Gonorrhoea Urethral discharge (B) Sexual contact (Ch, Xe) 27 days
Granuloma inguinale Ano-genital ulcers (B) Sexual contact (Ch, Xe) 116 weeks
Guama Fever (A) Culicine mosquito (Vc) 515 days
Guanarito H.F. Haemorrhagic fever (V) Inhalation or swallowing of 716 days
cane rat excreta (Hy, Ra)
Guaroa Fever (A) Culicine mosquito (Vc) 515 days
Guinea worm Leg worm (N) Water (swallowing infected 1 year
copepods) (Wa)
Haemorrhagic fever with Fever, haemorrhage, shock, Aerosol transmission from 24 weeks
renal syndrome oliguria (V) rodent urine, faeces and
saliva (Ra)
Hand, foot and mouth Stomatitis and skin lesions Direct contact with mouth 35 days
disease (V) lesions, airborne and
faecaloral (Hy)
Hantavirus pulmonary Fever, myalgia, respiratory Aerosol transmission from 16 weeks
syndrome distress and shock (V) rodent (deer mouse,
pack rats, chipmunks)
excreta (Ra)
Hanzalova Fever (A) Ixodes ticks (Vc)
Helicobacter pylori Gastritis, ulcer and Faecaloral or oraloral 510 days
adenocarcinoma (B) (Ch, Hy)
Hendra Encephalitis (V) Contact with horses, 418 days
reservoir in fruit bats (An)
Hepatitis A Jaundice (V) Faecaloral, water or food 1550 days
(Hy, Im, Fo, Wa)
Hepatitis B Jaundice (V) Inoculation, blood 6 weeks to 6 months
transfusion, sexual
contact, perinatal (Bl, Im,
Ne, Xe)
Hepatitis C Jaundice, chronic active Inoculation, blood 2 weeks to 6 months
hepatitis (V) transfusion, sexual
contact (Bl, Ne, Xe)
Hepatitis delta Jaundice, associated with Inoculation, sexual contact 28 weeks
HBV (V) (Im (HB vac.) Ne, Xe)
(Continued )
Hepatitis E Jaundice, mortality in Water-borne. Pig reservoir 39 weeks

pregnancy (V) (An, Hy, Wa)
Herpangina Pharyngitis (V) Contact with nose and 35 days
throat discharges,
faecaloral and airborne
(Hy, Wa)
Herpes genitalis Genital sores, in infants Sexual, oral and perinatal 212 days
encephalitis (V) contact (Xe)
Herpes simplex Cold sores or systemic Contact with saliva or 212 days
lesions in infants (V) lesions, perinatal (Hy)
Heterophyes Enteritis (H) Uncooked freshwater fish
(Fo)
Histoplasmosis Pulmonary and systemic Inhalation of spores from 317 days
lesions (F) soil (decrease dust)
Hookworm Anaemia (N) Larvae penetrate skin (Ch, 810 weeks
Hy, Sa, Wa, footwear)
Human (V) Fever, diarrhoea, weight Sexual contact, blood 118 years
immunodeficiency loss, opportunistic infection transfusion, needle-
virus transfer, perinatal (Bl,
Ne, Xe)
Human papilloma virus Genital warts (V) Sexual or direct contact 23 months
(Xe)
Hymenolepis Enteritis (H) Faecaloral, food or water 12 weeks
(Hy, Fo, Sa, Wa)
Ilesha Fever and rash (A) Vector (unknown) 312 days

Ilheus Encephalitis (A) Culicine mosquito (Vc) 515 days
Influenza Respiratory infection(V) Airborne droplets inhaled, 15 days
swallowed or direct
contact with mucous (Hy,
Im)
Inkoo Fever (A) Culicine mosquitoes (Vc) 515 days
Isospora Diarrhoea (P) Faecaloral and from dogs

and cats (An, Hy, Sa, Wa)
Issyk-Kul Fever (A) Tick vector (Vc) 45 days
Itaqui Fever (A) Culicine mosquito, rodent 312 days
reservoir (Vc)
Jamestown canyon Encephalitis (A) Culicine mosquito (Vc) 515 days

Japanese encephalitis Encephalitis (A) Culex mosquito, reservoir 515 days
in birds and pigs (Vc, Im)
Junin haemorrhagic fever Haemorrhagic fever (V) Aerosol or contact with 716 days
rodent excreta (Ra, Im)
Jurona Fever (A) Culicine mosquito (Vc)
Kaposis sarcoma Vascular neoplasia (V) Sexual contact, associated

with HIV infection (Xe)
Karshi Fever, encephalitis (A) Tick vector (Vc)
Kasokero Fever (A) Vector (unknown) 515 days
Kawasaki syndrome Fever and rash in children (T) Unknown, probably
airborne
Kemerovo Fever (A) Tick vector (Vc) 45 days
Kokobera Fever, arthritis (A) Culicine mosquito (Vc) 515 days
Koutango Fever and rash (A) Culicine mosquito (Vc) 515 days
Kumlinge Fever (A) Ixodes tick. Reservoir in
rodents and birds (Vc)
Kunjin Encephalitis (A) Culicine mosquito (Vc) 515 days
Kuru Cerebella ataxia (O) Eating human brain 420 years
(continued...)
296 Chapter 19
(Continued )
Kyasanur forest disease Haemorrhagic fever and Haemaphysalis tick. 38 days

encephalitis (A) Reservoir in rodents and
monkeys (Vc)
La Crosse Encephalitis (A) Aedes mosquito. Reservoir 515 days

in Aedes eggs, birds,
pigs (Vc)
Lassa fever Haemorrhagic fever (V) Mastomys excreta, human 621 days
blood and excretions,
sexual (Hy, Ne, Ra,
barrier nurse)
Le Dantec Encephalitis (A) Vector (unknown) 312 days
Legionellosis Pneumonia (B) Airborne aerosol of water 210 days
Leishmaniasis Cutaneous, mucocutaneous Phlebotomus, Lutzomyia 2 weeks to 6 months
and visceral lesions (P) sand flies. Mammalian
reservoir specific to
locality. Blood
transfusion and needles
(An, Bl, Ne, Vc)
Leprosy Skin and nerve lesions (B) Close personal contact and 120 years
possibly airborne (Ch,
Hy, Im)
Leptospirosis Fever and jaundice (S) Contact with rat, pig, cow or 419 days
dog urine or in water (An,
Ra)
Linguatula Nasopharyngitis (E) Eating raw liver of sheep,
goats and cows (Fo)
Lipovnik Meningitis (A) Tick vector (Vc) 45 days
Listeriosis Meningoencephalitis in Eating milk and cheese, 370 days
adults and neonates (B) contact with animals and
perinatal (An, Fo, Hy)
L. loa Calabar swelling (N) Chrysops fly (Ch, Vc) Years
Louping ill Encephalitis (A) Ixodes tick (Vc) 714 days
Lyme disease Erythematous migrans, Ixodes tick. Reservoir in 332 days
meningitis (S) ticks and mammals (An,
Im, Vc)
Lymphocytic C.M. Choriomeningitis (V) Excretions of mice in food, 813 days
contact or aerosol (Hy,
Fo, Ra)
Lymphogranuloma Ano-vaginal lesions (B) Sexual and direct contact 330 days
venereum with lesions (Ch, Xe)
Lympho-nodular Lymphonodular lesions in Direct contact with nose, 5 days
pharyngitis A pharynx (V) throat discharges and
faeces or by aerosol (Hy)
Machupo H.F. Haemorrhagic fever (V) Calomys rodent urine in 716 days
dust or through skin (Ra)
Madrid Fever (A) Aedes and Culex mosquito, 332 days
Malaria Fever (P) Anopheles mosquito, blood 917 days
transfusion (Bl, Ne, Vc) 1840 days
Manangle Fever and rash (V) Close contact with pig fluids 1418 days
and tissues (An, Hy)
Mansonella Fever, joint pain (N) Culicoides and Simulium
(Ch)
Marburg disease Haemorrhagic fever (V) Contact with blood and 221 days
body fluids (barrier
nurse)
Marituba Fever (A) Aedes and Culex mosquito, 312 days
(Continued )
Mayaro Fever, rash, arthritis (A) Mansonia and 311 days

Haemagogus mosquito
(Vc)
Measles Fever and rash (V) Airborne or contact with 1014 days
nose or throat secretions
(Im)
Melioidosis Pulmonary consolidation (B) Ingestion, inhalation or Months to years
broken-skin contact with
soil
Meningitis, viral Fever and meningitis (V) Airborne or contact with Depends on organism
nose and throat
secretions (Hy, Im)
Meningitis, Fever and meningitis (B) Airborne or contact with 210 days
meningococca nose and throat
secretions (Ch, Im)
Meningitis, Haemophilus Fever and meningitis (B) Airborne or contact with 24 days
nose and throat
secretions (Ch, Im)
Meningitis, Fever and meningitis (B) Airborne or contact with 13 days
pneumococcal nose and throat
secretions (Ch, Im)
Metagonimus Diarrhoea (H) Uncooked fish (Fo)
Microsporidiosis Diarrhoea (P) Ingestion, inhalation? (Hy)
Mokola Rabies-like illness (V) Animal saliva or bite (An)
Molluscum contagiosum Skin papules (V) Direct contact with lesions. 1950 days
Sexual contact (Hy, Xe)
Monkeypox Pox rash (V) Close contact with animal
or person-to-person (An,
Im)
Mononucleosis, infectious Glandular fever (V) Swallowing infected saliva 46 weeks
directly or on toys, etc.
(Hy)
Morumbi Fever (A) Culicine mosquito (Vc)
Mucambo Fever (A) Vector (unknown) 311 days
Mucormycosis Thrombosis and infarction (F) Inhalation, ingestion or
inoculation of spores
(Ne)
Mumps Parotitis (V) Airborne and contact with 1424 days
saliva (Im)
Murray Valley E. Encephalitis (A) Culex mosquito, reservoir 515 days
in birds (Vc)
Murutucu Fever (A) Culicine mosquito, rodent 312 days
reservoir (Vc)
Mycetoma Localized induration and Inoculation from soil or Months
sinuses (B, F) wood splinters or thorns
(footwear)
Mycoplasma Pneumonia Airborne droplets or direct 632 days
contact with secretions
(Hy)
Myiasis Furuncle, wound or various Fly larvae (Vc)
sites (E)
Naegleriasis Meningoencephalitis (P) Stagnant water in nasal 37 days

passages, e.g.
swimming
Nairobi sheep Fever (A) Tick vector (Vc) 45 days
Nasopharyngeal cancer Obstruction of naso-pharynx EpsteinBarr virus from Years
(V) saliva exchange
(continued...)
298 Chapter 19
(Continued )
Negishi Encephalitis (A) Vector (unknown) 515 days

Nepuyo Fever (A) Culicine mosquito, rodent 312 days
reservoir (Vc)
Nipah Encephalitis (V) Close contact with pig fluids 418 days
and tissues (An, Hy)
Nocardiosis Systemic abscesses(B) Inhalation of soil dust Weeks
Non-gonococcal Urithritis and discharge (B) Sexual contact (Xe) 12 weeks
urithritis
Non-Hodgkins lymphoma Lymphoma (V) Reactivated EBV infection
due to immunodeficiency
Norwalk or Norovirus Diarrhoea (V) Faecaloral, airborne or via 12 days
food and water (Hy, Fo,
Wa)
Nyando Fever (A) Culicine mosquito (Vc) 312 days
Omsk haemorrhagic Haemorrhagic fever (A) Dermacentor tick or contact 38 days

fever with muskrat (Im, Vc)
Onchocerciasis Blindness and skin damage Simulium fly (Vc) 1 year
(N)
Onyong-nyong Arthralgia (A) Anopheles mosquito (Vc) 312 days
Opisthorchis Liver damage (H) Uncooked freshwater fish 4 weeks
(Fo)
Opthalmia neonatorum Conjunctivitis in newborn (B) Genital secretions of 112 days
mother to infant (Ch, Hy, 619 days
Xe)
Orf Maculo-papular lesion (V) Contact with mucous 36 days
membranes of infected
sheep and goats (An, Hy)
Oriboca Fever (A) Aedes and Culex (Vc) 312 days
Oropouche Fever and meningitis (A) Culicine mosquito, 312 days
reservoir in monkeys,
sloths, birds (Vc)
Orungo Fever (A) Aedes and Anopheles (Vc) 312 days
Ossa Fever (A) Culicine mosquito, rodent 312 days
reservoir (Vc)
Osteomyelitis Bone abscess (B) Blood or wound infection 410 days
(Ch)
Otitis media Ear infection (B) Secondary to respiratory or 14 days
throat infection (Ch, Hy,
Im)
Paracoccidioidomycosis Mycosis of respiratory tract Airborne soil dust Months to years

and skin (F)
Paragonimus Lung damage (H) Freshwater crab/crayfish 610 weeks
(Fo)
Parainfluenza Croup, pneumonia (V) Respiratory or contact (Hy) 110 days
Paratyphoid Diarrhoea and rash (B) Faecal contamination of 110 days
food and water
(Hy,Fo,Im,Sa,Wa)
Pasteurellosis Cellulitis (B) Cat scratch or dog bite (An) 1224 h
Pediculosis Urticaria (E) From infested person 1014 days
(Hy,Vc)
Pertussis Whooping cough (B) Airborne droplets (Im) 710 days
Pinta Maculo-papular rash (S) Contact with lesions or by 13 weeks
flies (Hy, Ch, Sa, Wa)
Piry Fever (A) Vector (unknown) 312 days
Plague Bubonic Xenopsyla fleas (Vc, Ra) 26 days
Pneumonic (B) Airborne (barrier nurse) 14 days
Pneumococcal Pneumonia (B) Airborne droplets or direct 13 days
contact with discharges
(Im)
(Continued )
Pneumocystis Pneumonia (P/F) Airborne or reactivated 12 months

infection (Ch)
Pneumonia, chlamydial Pneumonia in neonates and To infant during birth; adult 112 weeks
adults by direct contact (Hy)
Poliomyelitis Paralysis (V) Faecaloral or respiratory 530 days
(Im)
Pongola Fever, arthritis (A) Culicine mosquito (Vc) 312 days
Powassan Encephalitis (A) Tick vector (Vc) 714 days
Psittacosis Pneumonia (B) Inhale bird droppings 515 days
(An,Hy)
Puerperal fever Genital tract infection Droplets, hands or faecal 13 days
following delivery (B) contamination (Hy, Ch)
Punta Toro Fever (A) Phlebotomus sand fly (Vc) 36 days
Q fever Fever, endocarditis (R) Direct from animal fluids, 23 weeks

airborne or milk (An, Hy,
Fo)
Quaranfil Fever (A) Tick vector (Vc) 45 days
Rabies Encephalomyelitis (V) Animal saliva via bite or 38 weeks

abrasion. Also bats (An,
Im)
Rat-bite fever Fever and rash (B, S) Rat bite, also secretions 13 weeks
(Ra)
Relapsing fever Periodic fever, mainly Pediculus louse (Hy, Vc) or 515 days
children (S) Ornithodorus tick (Ra, 310 days
Vc)
Respiratory syncytial virus Fever, rhinitis, pneumonia (V) Respiratory, contact or 28 days
swallowed (Hy)
Restan Fever (A) Culicine mosquito, rodent 312 days
reservoir (Vc)
Rheumatic fever Cardiac damage (B) Secondary to sore throat 13 days
from respiratory (droplet)
(Ch)
Rhinosporidiosis Growth in nose (B) Stagnant fresh water, 19 days
swimming
Rickettsial pox Fever and rash (R) Mite vector, rodent reser 313 days
(Vc)
Rift Valley Fever Haemorrhagic fever (A) Culex mosquito; contact 312 days
with animal tissues (An,
Vc)
Rio Bravo Encephalitis (A) Vector (unknown) 515 days
Rocio Encephalitis (A) Culex mosquito (Vc) 515 days
Rocky mountain spotted Fever and rash (R) Dermacentor & 314 days
fever Amblyomma ticks (An,
Vc)
Ross River Arthritis (A) Aedes & Culex mosquito 311 days
(Vc)
Rotavirus Diarrhoea (V) Faecaloral, respiratory, 13 days
direct or water (Hy, Wa,
Im?)
Rubella / CRS Rash in adults, neonatal Respiratory or direct to 1520 days
lesions (V) congenital (Im)
Russian springsummer Encephalitis (A) Ixodes tick (Vc) 714 days
encephalitis
Sabia haemorrhagic fever Haemorrhagic fever (V) Inhaled rodent excreta (Ra) 716 days
St Louis encephalitis Encephalitis (A) Culex mosquito (Vc) 515 days
Salmonellosis Diarrhoea (B) Meat, milk, eggs, 1236 h
faecaloral and water
(Hy, Fo, Wa)
(continued...)
300 Chapter 19
(Continued )
Sand fly fever Fever (A) Phlebotamus and 36 days

Lutzomyia sand fly (Vc)
Sarcocystis Diarrhoea (P) Uncooked meat (Fo)
Scabies Urticaria (C) Direct contact (Ch, Hy, Wa) 26 weeks
Scarlet fever Rash (B) Repiratory (Ch, Hy, Wa) 13 days
Schistosomiasis Liver or bladder damage (H) Water contact (Ch, Hy, Sa, 26 weeks
Wa, decrease water
contact)
Semliki Forest Encephalitis (A) Culicine mosquito (Vc) 312 days
Sepik Fever (A) Culicine mosquito (Vc) 515 days
Serra Norte Fever (A) Vector (unknown)
Severe acute respiratory Cough, pneumonia, difficult Respiratory, close contact, 114 days
syndrome breathing (V) faecaloral? (Hy)
Shingles Vesicular rash (V) Reactivated chickenpox 23 weeks
Shokwe Fever (A) Culicine mosquito (Vc) 312 days
Shuni Fever (A) Mosquito, Culicoides (Vc) 312 days
Simian B Meningoencephalitis (V) Monkey bite or contact with 3 days to 3 weeks
saliva (An, Hy)
Sindbis Arthritis, rash (A) Culex mosquito, reservoir 312 days
in birds (Vc)
Sleeping sickness Fever, headache, Glossina tsetse fly (An, Ch, Weeks to months
somnolence (P) Vc)
Smallpox Pox rash (V) Respiratory, skin contact 719 days
(Im)
Snowshoe hare Encephalitis (A) Culicine mosquito (Vc) 312 days
Sparganosis Subcutaneous nodules (H) Water, or eating frogs and
other amphibians (Fo,
Wa)
Spondweni Fever (A) Culicine mosquito (Vc) 312 days
Sporotrichosis Skin nodules (F) Percutaneous, inhalation 1 week to 3 months
from wood or sphagnum
moss
Staphylococcus Skin, wound, bone or organ Autoinfection, contact with 510 days
infections (B) lesions or flies (Ch, Hy,
Wa)
Streptococcal sepsis of the Pneumonia and meningitis Perinatal from genital tract 17 days
newborn (B) infection (Ch, Hy)
Streptococcal sore throat Inflamed throat and tonsils Respiratory or ingestion of 13 days
(B) food or milk (Ch, Hy, Fo)
Strongyloides Creeping eruption (N) Larvae penetrate skin, oral
or autoinfection (Hy, Sa)
Syphilis, endemic Skin and bone lesions (S) Shared drinking vessels 2 weeks to 3 months
and direct contact (Ch,
Hy, Wa)
Syphilis, venereal Skin, heart and CNS lesions Sexual or direct contact; via 990 days
(S) blood or congenital (Bl,
Ch, Xe)
T cell leukaemia Sarcoma, lymphoma or Breast milk, blood, needles

leukaemia (V) or sexual contact (Bl, Ne,
Xe)
Tacaiuma Fever (A) Anopheles mosquito (Vc) 312 days
Taenia saginata Tapeworm (H) Eating uncooked beef (An, 814 weeks
Fo)
Taenia solium Tapeworm and cysticercosis Uncooked pork, 812 weeks
(H) autoinfection, swallowing
eggs (An, Fo)
Tahyna Fever (A) Culicine mosquito (Vc)
Tamdy Fever (A) Tick vector (Vc) 45 days
Tataguine Fever and rash (A) Culicine mosquito (Vc) 515 days
Tensaw Encephalitis (A) Culicine mosquito (Vc) 312 days
Tetanus (and neonatal) Muscular contractions and Contamination of abraded 421 days
rigidity (B, T) skin or umbilicus (Hy, Im)
Thogoto Meningitis (A) Tick vector (Vc) 45 days
Tick-borne E. Encephalitis (A) Tick vector (Vc) 45 days
Tick typhus Fever (R) Dog tick vector and 115 days
reservoir (An, Vc)
Tinea Fungal skin and nail Direct skin contact, also 414 days
disease(F) animals (An, Hy, Wa)
Tonate Fever (A) Culicine mosquito (Vc) 312 days
Toscana Meningitis (A) Phlebotamus sand fly (Vc) 36 days
Toxic shock syndrome Fever and shock (B) Frequently associated with 410 days
absorbent tampons and 13 days
contraceptive in women
(Ch)
Toxocara Larva migrans (N) Ingestion of earth or food Weeks to months
contaminated with dog
and cat faeces (An, Hy,
Fo)
Toxoplasmosis Often asymptomatic in adult, Eating uncooked meat, 1020 days
but brain damage to earth contaminated with
neonate (P) cat faeces or direct from
cat (An,Hy,Fo)
Trachoma Red-eye, blindness (B) Contact with eye 512 days
discharges from fingers,
wipes and clothing. Flies
(Ch,Hy,Sa,Wa)
Trench fever Fever, endocarditis (B) Pediculus louse (Hy, Vc) 730 days
Trichinosis Fever and systemic cysts (N) Uncooked pork and other 815 days
meat (An, Fo, Ra)
Trichomonas Vaginitis (P) Sexual contact (Ch, Xe) 520 days
Trichuris Diarrhoea, debility in children Ingestion of soil and soil on 23 months
(N) vegetables (Hy, Fo, Sa,
Wa)
Trivittatus Fever (A) Culicine mosquito (Vc)
Tropical spastic paresis Myelopathy and spasticity (V) Blood or sexual contact (Bl,
Xe)
Tropical ulcer Skin ulcer with tissue loss (B) Contamination of abraded 27 days
skin. Flies (Hy, Sa, Wa)
Trubanaman Fever, arthritis (A) Culicine mosquito (Vc)
Tuberculosis Cough, weight loss and Respiratory, spitting 412 weeks
anaemia (B) Unpasteurized milk
(Ch,Im,Hy)
Tucunduba Encephalitis (A) Culicine mosquito (Vc)
Tularaemia Lymphadenopathy, systemic Tick, Chrysops, Aedes, 114 days
lesions (B) animal bite, from water
and meat or inhalation
(An, Hy, Fo, Vc)
Tunga Foot furuncles (E) Invasive flea (footwear)
Typhoid Fever and bowl ulceration (B) Faecal contamination of 330 days
food, water. Flies (Hy, Fo,
Im, Sa, Wa)
Typhus, epidemic Fever, prostration and rash Pediculus faeces 12 weeks
(B) scratched-in or inhaled
(Hy, Im, Vc)
Typhus, murine Fever and rash, mild (B) Xenopsylla flea faeces 12 weeks
inhaled (Hy, Ra, Vc)
(continued...)
302 Chapter 19
(Continued )
Typhus, scrub Fever, eschar and rash, mild- Leptotrombidium mite, 13 weeks
severe (B) reservoir in s. mammals
(Vc)
Usutu Fever, rash (A) Culicine mosquito (Vc) 312 days
Venezuelan equine E. Fever and encephalitis (A) Culicine mosquito, 26 days

reservoir in rodents and
horses (Im,Vc)
Vesicular stomatitis Fever, pharyngitis (A) Lutzomyia sand fly (Vc)
Wanowrie Fever and bleeding (A) Tick vector (Vc) 45 days

Warts Skin growths (V) Direct contact, inoculation 23 months
or indirect (e.g. floors)
(Hy)
Wesselsbron Fever (A) Culicine mosquito (Vc) 312 days
West Nile Fever (A) Culex mosquito, reservoir 312 days
in birds (Vc)
Western equine E. Encephalitis (A) Culex mosquito (Vc) 515 days
Wyeomyia Fever (A) Culicine mosquito (Vc) 312 days
Xingu Fever, hepatitis (A) Vector (unknown)
Yaws Skin and bone lesions (S) Contact with lesions and 28 weeks
exudates. Flies
(Ch,Hy,Sa,Wa)
Yellow fever Haemorrhagic fever (A) Aedes mosquito, reservoir 36 days
in monkeys (Im, Vc)
Yersiniosis Fever and diarrhoea (B) Faecaloral, contaminated 37 days
food and water. Pig
reservoir (An, Hy, Fo, Sa,
Wa)
Zika Fever (A) Culicine mosquito (Vc) 515 days

Index
Diseases are listed by the name most commonly used, such as whooping cough rather than pertussis, but
leptospirosis rather than Weils disease. Cross-references are given to all other names of each disease.
All countries where communicable diseases are commonly found are mentioned, except for European
countries where they are all under the single heading of Europe.
abacterial meningitis see meningitis, viral Ae. scutellaris group 201, 204, 205
Abate see temephos Ae. simpsoni 201, 205, 206, 207
abscesses see Staphylococcus Aeromonas 290
absettarov 290 Afghanistan 211, 267
acanthamoebiasis 173, 290 see also Asia, Central
acariasis see scabies Africa 2, 35, 84, 87, 95, 115, 117, 121, 122,
actinomycetoma see mycetoma 128, 131, 133, 139, 154, 161, 170,
actinomycosis 290 179, 181, 187, 191, 194, 201, 204, 206,
active case detection see surveillance, active 211, 228, 229, 237, 241, 248, 258,
acute haemorrhagic conjunctivitis see epidemic 260, 261, 265, 267, 271, 278, 280, 285,
haemorrhagic conjunctivitis 288
acute lymphonodular pharyngitis see Central 84, 192, 196, 229, 231, 234, 236, 261,
herpangina 267, 283, 287
acute respiratory infections (ARI) 13, 61, East 14, 19, 139, 191, 192, 201, 222, 231, 236,
146, 150, 164167, 172, 174, 175, 290 237, 252, 261
acute viral rhinitis see cold, common North 105, 176, 261, 267
adenoviral haemorrhagic conjunctivitis West 15, 117, 142, 179, 192, 195, 201, 222,
see epidemic haemorrhagic 229, 230, 231, 234, 246, 283, 287
conjunctivitis southern 141, 176
adulticides see vector control methods African haemorrhagic fever see Ebola
Aedes 65, 199, 222, 291, 292, 293, 296, 298, haemorrhagic fever
299, 302 African tick bite fever see tick typhus
Ae. aegypti 201, 204, 205, 206, 207 AIDS see HIV infection
Ae. aegypti index 66, 74, 208 akee poisoning 109, 111
Ae. africanus 201, 205, 206, 207 alenquer 290
Ae. albopictus 201, 204, 205 Aleppo boil see leishmaniasis, cutaneous
Ae. furcifer-taylori 201, 206 alphaherpesviral disease see herpes simplex
Ae. luteocephalus 201 Amazon 20, 181, 195, 246
303
304 Index
America 14, 106, 117, 118, 128, 171, 191, 192, South 105, 176, 191, 201, 203, 204, 211, 248,
201, 241 258, 278
Central 84, 117, 148, 161, 176, 181, 194, 201, Southeast 14, 15, 19, 35, 84, 105, 111, 133,
204, 206, 211, 229, 241, 242, 246, 179, 191, 199, 201, 203, 204, 211,
248, 261, 278, 280 224, 258, 287
North 87, 161, 175, 195, 266, 267, 285, 288 Southwest (Middle East) 142, 195, 211, 246,
South 13, 19, 68, 84, 87, 95, 117, 128, 248, 267, 278, 280
139, 148, 161, 176, 179, 181, 192, Aspergillosis 291
194, 201, 204, 206, 211, 218, 224, athletes foot see tinea
228, 229, 232, 242, 246, 248, 260, attack rate 25
261, 271, 278, 280 Australia 19, 84, 111, 175, 187, 201, 203, 258, 265,
amoebiasis (amoebic dysentery)10, 42, 43, 44, 45, 287, 288
51, 74, 90, 97, 98100, 290 Australian encephalitis see Murray Valley
see also Entamoeba histolytica encephalitis
amoebic meningoencephalitis see autoinfection 120, 130
acanthamoebiasis and naegleriasis avian chlamydiosis see psittacosis
Ancylostoma 127129, 270, 275, 276
see also hookworm
Angiostrongylus 173, 291 B-virus see simian B
Angola 154 babesiosis 291
see also Africa baboons, diseases associated with 201, 292
Anopheles 15, 199, 211, 220224, 225, 296, 298, bacillary dysentery 74, 90, 9798, 123, 291
300 Bacillus anthracis 278, 280
A. culicifacies 211, 212 cereus 90, 108, 109
A. farauti 211 sphaericus 57, 217
A. fluviatilis 211 thuringiensis 57, 217, 230
A. funestus 211 see also anthrax
A. gambiae 68, 201, 211, 212, 222 Baghdad boil see leishmaniasis, cutaneous
A. sinensis 14, 211 Balantidiasis 90, 113, 291
see also malaria bancroftian filariasis see filariasis, lymphatic
anisakiasis 291 Bangladesh 20, 95, 246
anthrax 5, 68, 74, 123, 270, 279281, 289, 291 see also Asia
vaccination 280 bangui 291
apeu 291 banzi 291
apoi 291 Barmah Forest disease 291
aphthous pharyngitis see herpangina bartonellosis 291
Arabian peninsula 14, 139, 181, 211, 267 basic reproductive rate 2627
see also Asia, Southwest batai 291
arbovirus infections 20, 42, 45, 54, 77, 144, 173, bats, disease associated with 196, 201, 270,
199208, 267268, 270, 288 271272, 273, 286, 288, 292, 294, 299
Arctic 20, 118, 122, 175 Bayliscaris procyonis 275
Argentina 242, 266 BCG 34, 36, 37, 38, 84, 154155, 159, 161162,
see also America, South 163, 166
Argentine haemorrhagic fever see Junin bears, disease associated with 118
haemorrhagic fever bedbug 56, 60, 194
ARI see acute respiratory infections bednets, impregnated see mosquito-nets,
armadillos 241, 243, 244 treated
armillifer 291 beef tapeworm see Taenia saginata
Ascaris 3, 5, 6, 42, 43, 44, 45, 51, 113, 123, 124, bejel see syphilis, endemic
125127, 291 Belize 246
aseptic meningitis see meningitis, viral see also America, Central
asexual reproduction 3, 199, 208209 benign lymphoreticulosis see cat-scratch
Asia 14, 86, 87, 95, 117, 122, 133, 154, 161, 187, fever
194, 201, 208, 252, 266, 271, 288 bhanja 291
Central 195, 211, 246, 248, 267, 278 bilharzia see schistosomiasis
East 112, 117, 128, 201, 224, 252, 258, 287 biological control see vector control
Northeast 265 bioterrorism 281, 284, 288289
Index 305
birds, diseases associated with 111, 120, 167, canicola fever see leptospirosis
201, 202, 203, 277, 280, 286287, 288, capillariasis 291
293, 295, 296, 297, 298, 299, 300, 302 hepatic 291
blastomycosis 291 intestinal 291
bladder, cancer of 2, 136 pulmonary 291
blindness 84, 86, 87, 146, 150, 155, 275 capnocytophaga 270, 292
bluetongue 291 caraparu 292
body fluids, transmission by 78, 178197 carate see pinta
boils, carbuncles see Staphylococcus carbamates 59
Bolivia 115, 258 Caribbean 20, 87, 111, 139, 179, 187, 192, 201,
see also America, South 204, 224
Bolivian haemorrhagic fever see Machupo carriers 7, 1011, 21, 64, 9495, 95, 97, 101102,
haemorrhagic fever 103, 110, 168, 169
Bornholm disease see epidemic myalgia Carrions disease see bartonellosis
Botswana 191 case control investigation 28
see also Africa cassava poisoning 109, 111
botulism 109, 289, 291 cats, diseases associated with 92, 111, 116, 117,
Boutonneuse fever see tick typhus 118, 119, 252, 257, 269, 270, 271, 273,
bovine spongiform encephalopathy (BSE) 68, 285 275, 276, 277, 280, 288, 292, 295
Brazil 142, 154, 201, 222, 230, 242, 266, 274 cat-scratch fever 292
see also America, South catarrhal jaundice see hepatitis A
Brazilian haemorrhagic fever see sabia cattle, diseases associated with 92, 108, 111, 112,
haemorrhagic fever 115, 120, 132, 142, 201, 202, 265, 269,
Brazilian purpuric fever 291 270, 271, 273, 277280, 281, 285, 286, 296
see also conjunctivitis, acute bacterial catu 292
breakbone fever see dengue Central African Republic (CAR) 139, 154, 230,
breast feeding 90, 97, 106, 146, 165, 166, 193 283
Breteau index 208 see also Africa
Brill-Zinsser disease see typhus, recurrent Central Asian haemorrhagic fever see Crimean-
broad tapeworm see Diphyllobothrium Congo haemorrhagic fever
Brucella 270, 277 Central European encephalitis 292
brucellosis 44, 123, 277278, 291 cercopithecine herpes virus 1 see simian B
Brugia malayi 219, 220, 221223, 225, 226, 270 cerebrospinal fever see meningitis,
B. timori 219, 220, 222, 226, 228 meningococcal
B. pahangi and B. patei 275 cervical cancer 2, 189, 190
see also filariasis, lymphatic see also human papilloma virus
bunyamwera 291 Chad 139, 246
Burkitts lymphoma 2, 291 see also Africa
Burma see Myanmar Chagas disease 3, 9, 13, 69, 190, 241243, 270,
buruli ulcer 8384, 291 292
Burundi 230, 258 vectors 241, 243
see also Africa chagres 292
bussuquara 291 chancroid 187188, 292
bwamba 291 chandipura 292
changuinola fever 292
charbon see anthrax
California encephalitis 291 Chesson strain 208
Cambodia 117, 141, 192, 203, 287 chickens, disease associated with 108, 111, 167,
see also Asia 277, 286, 287
camels, diseases associated with 202, 252 see also birds,
Cameroon 139 chickenpox 11, 24, 144145, 173, 189, 292, 300
see also Africa chiclero ulcer see leishmaniasis, mucocutaneous
Campylobacter 43, 44, 45, 51, 89, 90, 111112, chikungunya 199, 201, 292
173, 270, 291 Chile 121, 242
Canada 200, 266, 274, 286 see also America, South
candidiasis 146, 189, 190, 291 China 14, 20, 105, 112, 116, 117, 118, 139, 142,
candiru 291 167, 191, 192, 203, 211, 222, 224, 246,
306 Index
China (continued ) creeping eruptions 292

248, 258, 265, 267, 267, 276, 285, 286, 287, Creutzfeld-Jakob disease 285286, 292
289 CrimeanCongo haemorrhagic fever 197, 201,
see also Asia 202, 267268, 288, 292
Chlamydia 2, 3, 84, 87, 173, 185, 186 critical population 27
chlorination 44, 95, 98, 99, 101, 142 critical rate of vaccination coverage 28
cholangiocarcinoma 2, 115 croup see acute respiratory infections
cholera 7, 10, 14, 28, 42, 43, 44, 45, 52, 73, 74, 89, cryptococcosis 173, 189, 190, 292
90, 9296, 98, 292 cryptosporidiosis 90, 92, 189, 270, 292
classical 14, 92, 93, 95 Culex 14, 201, 202, 203, 222224, 291, 295, 296,
El Tor 14, 92, 93, 95, 123 297, 298, 299, 300, 302
vaccination 91, 9596 Culex quinquefasciatus 51, 57, 201, 222
see also Vibrio cholerae Culicoides 291, 296, 300
chromomycosis 292 Cyclospora 292
Chrysops 234, 289, 296, 301 cysticercosis see Taenia solium
climate 15, 21, 165, 198, 213 cytomegalovirus infection 2, 189, 292
see also seasonality
Clonorchis see Opisthorchis
Clostridium botulinum 7, 109, 289 Dakar bat 293
perfringens 90, 108, 109, 110 deafness 150, 175176
see also botulism deerfly fever see tularaemia
coccidioidomycosis 189, 292 DEET 55, 258, 263
cohort study 28 Delhi boil see leishmaniasis, cutaneous
cold, common 67, 164, 167, 292 dengue 3, 20, 54, 65, 66, 73, 199, 201, 202,
Colombia 230, 266, 274 204206, 292
see also America, South haemorrhagic fever 204
Colorado tick fever 292 Dermacentor 263264, 265, 267, 292, 298, 299
communicability, period of see period of dermatitis verrucosa see chromomycosis
communicability Dermatophagoides 293
condylomata acuminata see human papilloma dermatophytosis see tinea
virus desert fever see coccidioidomycosis
congenital cytomegalovirus 292 devils grippe see epidemic myalgia
see also cytomegalovirus infection dhori 293
Congo 139, 154, 196, 230, 234, 236, 283, 285, 287 Dibothriocephaluslatus see Diphyllobothrium
see also Africa di-ethyl-toluamide see DEET
conjunctivitis 43, 45, 145, 173, 292 diarrhoeal diseases 3, 9, 14, 15, 18, 20, 42, 43, 44,
adenoviral haemorrhagic see epidemic 45, 51, 64, 90
haemorrhagic conjunctivitis diethylcarbamazine (DEC) 132, 224, 227228,
chlamydia see ophthalmia neonatorum 234, 276
enteroviral haemorrhagic see epidemic diphtheria 3, 10, 11, 22, 73, 74, 168169, 293
haemorrhagic conjunctivitis vaccination 35, 166, 169
gonococcal see ophthalmia neonatorum Diphyllobothrium 9, 42, 44, 51, 113, 118119,
contacts/contact tracing 32, 67, 159, 183 270, 293
contagious pustular dermatitis see orf Dipylidium 270, 293
contour drains 58 Dirofilaria 270, 275, 276, 293
cooking of food 34, 108, 110, 112, 117, 118, 119, dog tapeworm see Dipylidium
121 dogs, diseases associated with 61, 92, 111,
cooking oil poisoning 7, 109 116, 117, 118, 119, 132, 142, 243,
copepods 118, 119, 294 244, 246, 248, 252, 265, 266, 269,
coryza see cold, common 270, 271, 273, 274275, 276, 277, 278,
costbenefit analysis 13 280, 282, 288, 292, 293, 295, 296, 298,
cost-effectiveness analysis 13 301
Costa Rica 266 donovanosis see granuloma inguinale
see also America, Central dracunculiasis (Dracunculus medinensis) see
Cote dIvoire 154 Guinea worm
see also Africa dugbe 293
coxsackievirus carditis see enteroviral carditis Dursban see chlorpyrifos
Index 307
Duvenhage 269, 293 extended source 2325

dwarf tapeworm see Hymenolepis propagated source 23, 2526
threshold 22
epidemic arthritic erythema see rat-bite fever
earth, eating see pica epidemic haemorrhagic conjunctivitis 8687,
eastern equine encephalitis 200, 268, 293 293
ebola haemorrhagic fever 25, 196, 197, 285, 293 epidemic haemorrhagic fever see haemorrhagic
EBV mononucleosis see mononucleosis, fever with renal syndrome
infectious epidemic jaundice see hepatitis A
Echinococcus 270, 293 epidemic keratoconjunctivitis 87, 293
E. granulosus 270, 272 epidemic myalgia 293
E. multilocularis 270, 274 epidemic pleurodynia see epidemic myalgia
E. vogeli 270, 275 epidemic polyarthritis see Ross River fever
Echinostoma 270, 293 epidemic viral gastroenteropathy see Norwalk
economics see health economics epidermophytosis see tinea
ecthyma contagiosum see orf Epstein-Barr virus (EBV) 2, 297, 298
ectoparasites 60, 78, 79, 249268 eradication programmes 6869, 143, 148,
control of 60, 252254, 258259, 260, 263, 179, 217
264265, 265, 266, 268 erysipelas 151
see also bedbugs, fleas, lice, mites, ticks see also streptococcal infections
Ecuador 115, 230, 252, 274 erythema infectiosum 293
see also America, South Escherichia coli 78, 89, 90, 97, 173, 270
edge hill fever 293 E. coli 0157, 293
education 12 espundia see leishmaniasis, mucocutaneous
Egypt 20, 95, 115, 222 Ethiopia 20, 105, 143, 230, 246, 258, 260
see also Africa, North see also Africa
ehrlichiosis 293 eumycetoma see mycetoma
El Nino 19, 111 Europe 2, 87, 95, 106, 117, 118, 121, 122, 161,
encephalitis lethargica 293 162, 171, 191, 192, 194, 195, 201, 252,
endemicity 2829 266, 267, 285
endocarditis see staphylococcal and everglades fever 293
streptococcal infections eye diseases 42, 79, 8488
Endolimax nana 113 eyeworm disease of Africa see Loa loa
Entamoeba coli 100, 113 exanthem subitum 293
E. histolytica 5, 6, 7, 10, 90, 98, 99, 113 excreta disposal see sanitation
see also amoebiasis
enteritis necroticans 109, 293
Enterobius 9, 42, 43, 45, 107, 113, 293 faecaloral diseases 42, 43, 78, 79, 88, 89123,
enteroviral carditis 293 123, 291, 292, 293, 294, 298, 299, 300,
enteroviral haemorrhagic conjunctivitis see 301, 302
epidemic haemorrhagic conjunctivitis Far-Eastern tick-borne encephalitis see Russian
enteroviral lymphonodular pharyngitis see springsummer encephalitis
lymphonodular pharyngitis, acute Fasciola 112,113, 114, 115, 293
enteroviral vesicular pharyngitis see herpangina Fasciolopsis 10, 42, 44, 51, 112115, 294
enteroviral vesicular stomatitis with exanthem favus see tinea
see hand, foot and mouth disease fifth disease see erythema infectiosum
entomophthoramycosis 293 Fiji 1, 146, 222
environment 1220, 34 see also Pacific Islands,
physical 1420 filariasis, lymphatic 3, 26, 42, 45, 51, 61, 69, 81,
social 1214 219228, 294
environmental control methods 32, 4052, 53 vectors 220222
modification see vector control methods see also Wuchereria bancrofti and Brugia
see also sanitation, water, water supplies malayi
eosinophilic meningitis see Angiostrongylus fish, in disease transmission 93, 109, 110111,
epidemics 2228 115116, 118119, 123, 282, 290, 293,
common source 2325 294, 295, 297, 298
point source 2324 poisoning 110111, 294
308 Index
fish tapeworm see Diphyllobothrium Guatemala 230, 233, 246, 258

fleas 9, 43, 45, 56, 60, 79, 249252, 256, 257, 258, see also America, Central
270, 293 Guinea 154, 283
flies/housefly 9, 41, 42, 43, 51, 83, 84, 86, 89, 96, Bissau 283
97, 99, 101, 102, 120, 151, 152, 178, 279, see also Africa
291, 292, 297, 301, 302 Guinea worm 42, 45, 68, 142143, 270, 294
focality/focus 9, 29, 249, 250, 252, 253, 255, 258, Guyana 218
261 see also America, South
geographical 29, 267
host 29
food, diseases transmitted by 93, 102, 103, 104, Haemagogus 206, 207, 297
108123, 291, 298, 299, 300, 301 Haemophilus influenzae infection 164, 172, 173,
poisoning 7, 23, 28, 74, 90, 103, 108110, 175
294 Vaccination 35, 166, 162
investigation of 28, 29, 110 haemorrhagic fever with renal
food hygiene/protection of food 4143, 77, 98, 99, syndrome 294
102, 108, 110, 127, 282, 290 haemorrhagic jaundice see leptospirosis
footwear in prevention 130, 132, 141, 276, 301 haemorrhagic nephrosonephritis see
force of infection 21 haemorrhagic fever with renal
Fore people 11, 285 syndrome
Fort Sherman fever 294 hairy cell leukaemia see T-cell leukaemia/
foxes, diseases associated with 118, 246, 271, lymphosarcoma
273, 274 Haiti 133, 135, 211
frambesia see yaws hand, foot and mouth disease 294
Hansens disease see leprosy
hantavirus, pulmonary syndrome 294
G-6-P-D deficiency 218 hanzalova 294
Gabon 139, 196 Haverhill fever see rat-bite fever
see also Africa health economics 13
gammaherpesviral mononucleosis see in vaccination programmes 13, 3839
mononucleosis, infectious in TB diagnosis 157
gan gan 294 Helicobacter pylori 2, 294
ganjam see Nairobi sheep disease Hendra 287288, 294
Gastrodiscoides 294 hepatitis A 22, 42, 44, 45, 51, 74, 78, 103104,
gastroenteritis 20, 77, 8992, 94, 111, 294 105, 123, 294
geographical information systems (GIS) 20 vaccination 104
gerbils, diseases associated with 246 hepatitis B 2, 3, 10, 61, 67, 74, 78, 79, 193194,
German measles see rubella 294
Germiston 294 vaccination 34, 36
Ghana 86, 143 hepatitis C 3, 74, 194195, 294
see also Africa hepatitis delta 195, 294
Giardia 43, 44, 45, 51, 78, 90, 98, 113, hepatitis E 104105, 295
123, 294 hepatocellular cancer 2, 36, 193, 195
Gilchrists disease see blastomycosis see also hepatitis B
glandular fever see mononucleosis, infectious herd immunity see immunity, herd
global warming 1920, 198, 213 herpangina 295
glomerulonephritis, acute 151 herpes genitalis 295
Glossina 235, 237, 239, 300 herpes simplex 2, 173, 188, 189, 190, 295
Gnathostoma 270, 276, 294 herpes zoster see chickenpox
goats, diseases associated with 115, 202, 277, Heterophyes 113, 117, 270, 295
280, 296, 298 histoplasmosis 189, 295
milk and cheese 123, 278 HIV infection 2, 3, 11, 14, 36, 61, 67, 73, 81,
gonorrhoea 3, 183185, 294 92, 144, 147, 159, 161162, 173, 182,
granuloma inguinale 187, 294 187, 188, 189193, 245, 248, 276, 285,
guama 294 286, 295
guanarito haemorrhagic fever 294 hookworm 3, 5, 7, 21, 30, 42, 51, 113, 123, 124,
guaroa 294 127130, 295
Index 309
horses, diseases associated with 132, 200202, jackals, diseases associated with 121122, 246,
280, 288, 294, 302 271, 273
human papilloma virus 2, 188189, 295 Jamestown Canyon encephalitis 295
human parvovirus infection see erythema Japan 116, 117, 118, 139, 142, 167, 203, 258,
infectiosum 267, 287
hydatid disease 45, 123, 272275 see also Asia
see also Echinococcus Japanese encephalitis 3, 14, 20, 2002002,
hydrophobia see rabies 203204, 268, 295
hyenas, diseases associated with 121122, 271 Junin haemorrhagic fever 295
Hymenolepis 44, 45, 51, 113, 295 jurona fever 295
hyrax, diseases associated with 246
kala-azar see leishmaniasis, visceral

ilesha 295 Kaposis sarcoma 2, 190, 284, 295
ilheus 295 karelian fever see sindbis
immunity 12 karshi 295
herd 27, 106 kasokero 295
immunization see vaccination Kawasaki syndrome 295
impetigo 151 Kemerovo 295
see also staphylococcal and streptococcal Kenya 20, 196, 233, 246, 274
infections see also Africa
inclusion conjunctivitis see ophthalmia Kenya tick typhus see tick typhus
neonatorum keratoconjunctivitis see epidemic
incubation period 2225 keratoconjunctivitis
India 15, 95, 121, 142, 154, 161, 171, 179, kerion see tinea
192, 199, 201, 203, 211, 222, 227, kokobera 295
246, 248, 258, 260, 265, 267, 271 Korea 117, 203, 287
see also Asia see also Asia
India tick typhus see tick typhus Korean haemorrhagic fever see haemorrhagic
Indonesia 112, 121, 139, 161, 187, 203, 208, 211, fever with renal syndrome
222, 224, 287, 288 koutango 295
see also Asia kumlinge 295
infantile paralysis see poliomyelitis kunjin 295
infectious hepatitis see hepatitis A kuru 11, 285, 295
infectious mononucleosis see mononucleosis, Kyasanur Forest disease 201, 202, 267, 296
infectious
infectious parotitis see mumps
infective dose 7, 102, 104 La Crosse encephalitis 296
influenza 7, 64, 67, 73, 164, 166167, 173, Laos 117, 139, 203, 287
286287, 295 see also Asia
avian 167, 286287 larva currens 130
vaccine 166 larva migrans 127,130, 275276
inkoo 295 larvicides see vector control methods
insect-borne diseases 78, 79, 198248 laryngitis see acute respiratory infections
insecticides see vector control methods Lassa fever 11, 32, 61, 197, 282283, 285,
International health regulations 73 296
interstitial plasma-cell pneumonia see latency 6
Pneumocystis latent period 22
Iraq 139, 267 Le Dantec 296
see also Asia legionellosis 173, 296
Iran 115, 267 Leishmania 244, 245, 246, 248
see also Asia leishmaniasis 3, 190, 244248, 270, 296
Isospora 189, 270, 295 leprosy 3, 11, 43, 45, 61, 67, 74, 78, 152155, 190,
Israel 199 245, 296
Israeli tick typhus see tick typhus see also BCG and Mycobacterium leprae
issyk-kul 295 leptospirosis 43, 44, 45, 61, 74, 173, 270,
itaqui 295 281282, 296
310 Index
Liberia 154, 283 mathematical models 26, 31, 148, 213216,

see also Africa 222223
lice 43, 45, 56, 60, 79, 8182, 144, 256, 257258, mayaro fever 297
260, 298, 299 measles 1, 3, 11, 12, 14, 18, 21, 25, 63, 74,
Linguatula 270, 296 77, 78, 145149, 151, 159, 165, 166, 173,
lipovnik 296 297
listeriosis 173, 296 vaccination 34, 3536, 37, 38, 147149, 166
Loa loa/loiasis 221, 234, 296 meat, hygiene and inspection of 42, 43, 121, 282
lockjaw see tetanus medical geography 20
louping ill 296 Mediterranean 128, 195, 248, 265, 278
lues see syphilis, venereal Mediterranean fever see brucellosis
lung fluke see Paragonimus Mediterranean spotted fever see tick typhus
Lutzomyia 246, 291, 292, 296, 300, 302 Melanesia 211
lyme disease 173, 266267, 296 see also Pacific Islands
lymphatic filariasis see filariasis, lymphatic melioidosis 297
lymphocytic choriomeningitis 173, 296 meningitis 3, 10, 61, 74, 173, 297
lymphogranuloma venereum (inguinale) African epidemic belt 170171, 173
186187, 296 Haemophilus 35, 173, 297
lymphonodular pharyngitis, acute 296 meningococcal 74, 144, 169171, 173,
lyssa see rabies 297
Lyssavirus 287 pneumococcal 77, 172174, 297
viral 173, 297
Metagonimus 117, 270, 297
Machupo haemorrhagic fever 296 metapneumovirus 164, 173
Madagascar 154, 222, 252 Mexico 105, 121, 230, 246, 266
see also Africa see also America, Central
Madrid fever 296 Microsporidiosis 189, 297
Madura foot see mycetoma microsporosis see tinea
malaria 2, 3, 7, 12, 14, 1920, 42, 45, 52, 5455, Middle East see Asia, Southwest
63, 64, 6667, 68, 69, 71, 73, 74, 79, 127, Miombo forest 237
171, 198, 199, 208219, 291, 296 mite 9, 60, 80, 255, 256, 293, 299
forest fringe 14 islands 14, 255257
life cycle 209, 215 mobile clinics 13, 18, 38
mathematical model 26, 213216 see also vaccination
see also Anopheles mosquitoes and mokola 269, 297
Plasmodium molluscum contagiosum 297
Malawi 230 mongoose, diseases associated with 271, 273,
see also Africa 282
Malayan filariasis see filariasis, lymphatic moniliasis see candidiasis
Malaysia 95, 112, 141, 203, 211, 222, 258, 288 monkeys, diseases associated with 10, 201, 204,
see also Asia 206, 207, 222, 252, 285, 286, 287, 296,
Mali 283 298, 300
see also Africa monkeypox 26, 287, 297
malignant pustule see anthrax mononucleosis, infectious 297
Malta fever see brucellosis morumbi 297
malnutrition 20, 37, 127, 130, 146, 156, 159, mosquito nets 5556, 77, 202, 216, 218
164 insectide treated 56, 81, 216, 217, 218, 219,
manangle 287288, 296 224, 227, 243, 248
Mansonella 234, 296 mosquitoes 9, 42, 77, 198200, 201, 211212,
Mansonia 222, 225, 297 288, 289
Marburg disease 196, 197, 285, 296 control of see vector control
marginal costs 13 see also Anopheles and Culex
marituba 296 movements, of people 13
Marseilles fever see tick typhus Mozambique 154
mass drug administration (MDA) 61, 142, see also Africa
224227, 233 MRSA see staphylococcal infections
Mastomys natalensis 250, 271, 282283, 296 mucambo 297
Index 311
mucocutaneous lymph node syndrome see Norwalk 298

Kawasaki syndrome notification of disease 7376, 96, 193, 196, 254,
mucormycosis 297 280, 282, 283
mud fever see leptospirosis England and Wales 74
Multiceps 270 WHO 73, 96, 193, 196, 204, 208, 254, 260,
mumps 150151, 173, 297 283
vaccination 36, 151 nyando 298
Murray Valley encephalitis 200, 297
murutucu 297
Myanmar 95, 105, 154, 161, 203 occupational diseases 14, 139, 236, 237, 278, 280,
see also Asia 281
mycetoma 297 ockelbo see sindbis
Mycobacterium 189, 270 Ohara disease see tularaemia
M. africanum 157 Omsk haemorrhagic fever 267, 298
M. bovis 157 Onchocerca volvulus 221, 228, 233, 234
M. leprae 152155 onchocerciasis 3, 42, 45, 81, 228234
M. tuberculosis 157, 161162, 163, 173 vectors 230
M. ulcerans 83, 84 onychomycosis see tinea
Mycoplasma infection 164, 173, 185, 297 onyong nyong 199, 201, 298
myiasis 297 Opisthorcis 2, 9, 42, 44, 51, 101, 113, 115117,
270, 298
opossum, diseases associated with 283
naeglariasis 173, 297 ophthalmia neonatorum 74, 8788, 185, 298
Nairobi sheep fever 297 oral rehydration solution (ORS) 9091, 96, 98,
nasopharyngeal cancer 2, 297 112
Nauru leprosy epidemic 154 orf 298
Necator americanus 127129 organophosphates 59
see also hookworm oriboca 298
negishi 298 oriental sore see leishmaniasis
neonatal inclusion blennorrhoea see ophthalmia Ornithodorus 261263, 299
neonatorum ornithosis see psittacosis
Nepal 154, 165, 171, 203, 211 oropouche 199, 201, 298
see also Asia Oroya fever see bartonellosis
nephropathia epidemica see haemorrhagic fever orungo 199, 201, 298
with renal syndrome ossa 298
nepuyo 298 osteomyelitis 298
New Zealand 201 see also staphylococcal and streptococcal
New Guinea, island of 84, 109, 187, 201, 218, 222 infections
New World spotted fever see Rocky Mountain otitis media 3, 77, 146, 174, 175176, 298
spotted fever see also staphylococcal and streptococcal
Niger 154 infections
see also Africa outbreak, investigation of 2426, 6266
Nigeria 143, 206, 234, 278, 283 oxyuriasis see Enterobius
see also Africa
nipah 287288, 298
njovera see syphilis, endemic Pacific, Islands 20, 82, 87, 95, 109, 111, 161, 171,
nocardiosis 173, 298 175, 176, 179, 195, 201, 204, 218, 219,
nomads/pasturalists 13, 280 224, 258, 288
non-A non-B hepatitis see hepatitis C and E Western 106, 115, 133, 194, 218
non-gonococcal urethritis (NGU) 183, 185186, Pakistan 142, 258, 267
298 see also Asia
non-Hodgkins lymphoma 2, 298 Panama 206, 266
non-venereal syphilis see syphilis, endemic see also America, Central
norovirus see Norwalk Panstrongylus 241, 243
North American tick typhus see Rocky Mountain papatasi fever see sandfly fever
spotted fever Papua New Guinea 2, 19, 131, 174, 187, 208, 285
North Asian tick fever see tick typhus paracoccidioidomycosis 298
312 Index
Paragonimus 9, 42, 44, 51, 113, 117118, 270, 298 chlamydial 173, 299
Paraguay 154 Haemophilus 35, 173
see also America, South pneumococcal 172174, 299
parainfluenza 173, 298 viral 173
parapertussis see whooping cough see also staphylococcal and streptococcal
paratrachoma see opthalmia neonatorum infections
paratyphoid 74, 102, 103, 298 pogosta disease see sindbis
parotitis see mumps poliomyelitis 3, 7, 10, 11, 12, 68, 71, 73, 74, 86,
parrot fever see psittacosis 105106, 173, 284, 299
passive case detection see surveillance, passive eradication programme 68, 106
pasteurellosis 270, 298 vaccination 34, 35, 37, 106
pasteurization of milk 101, 108, 111, 112, polystyrene beads 57, 227
161, 278 Polynesia 222, 224, 227
pediculosis 298, see lice pongola 299
period of communicability 22 Pontiac fever see legionellosis
personal hygiene 41, 43, 60, 77, 81, 82, 86, 87, 88, pork tapeworm see Taenia solium
89, 92, 98, 99, 102, 104, 107, 110, 127, 151, poultry see chickens
174, 259, 260, 290 powassan 299
persistence of pathogens 5, 6 pregnancy/pregnant women 11, 15, 104, 105,
pertussis 298 144, 159, 162, 183, 277
see also whooping cough primary amoebic meningoencephalitis see
Peru 115, 246, 258 naegleriasis
see also America, South primary atypical pneumonia see Mycoplasma
peste or pestis see plague infection
pharyngoconjunctival fever see epidemic primary liver cell cancer see hepatocellular
haemorrhagic conjunctivitis cancer
Philippines 117, 139, 196, 203, 211, 222, 288 pseudotuberculosis see yersiniosis
see also Asia psittacosis 299
Phlebotamus 246, 290, 291, 292, 296, 299, 300, 301 puerperal fever 151,152, 299
Phlebotamus fever see sandfly fever pulmonary distomiasis see Paragonimus
phycomycosis see mucormycosis punta toro 299
pica 124, 291 pyrethroids 54, 56, 59, 81, 82, 258
pigs, diseases associated with 92, 104, 111, 112,
116, 120, 121, 122, 132, 142, 167, 201,
203, 277, 281, 286, 287288, 291, 295, Q fever 299
296, 302 quantitative dynamics 3031
pilot programme 71 quaranfil 299
pinta 88, 179181, 298 quarantine 32, 64, 95, 254
pinworm see Enterobius Queensland tick typhus see tick typhus
piry 298 quintana fever see trench fever
plague 1, 9, 43, 61, 73, 74, 77, 249254, 279, 288,
289, 298
bubonic 61, 249 rabbit fever see tularaemia
foci 252253 rabies 12, 74, 269272, 279, 299
pneumonic 249250 vaccination 32, 272273
wild rodent 60, 250, 252 post-exposure guide 273
plants in disease transmission 10, 99, 104, 112, raccoon, diseases associated with 271, 273,
114, 115 275276
water plants 112, 114, 115, 293, 294 rainfall, 15, 66, 139, 212
Plasmodium berghei 11 rats, diseases associated with 78, 116, 122, 142,
P. falciparum 208210, 212, 213 241, 243, 249, 250, 252, 255, 257, 259,
P. malariae 208, 210, 212, 213 261, 275, 281282, 282283, 290, 294,
P. ovale 208210, 212 296, 299
P. vivax 208210, 212, 213 control of 61, 78, 254, 259, 282, 290
see also malaria tapeworm see Hymenolepis
Pneumocystis 173, 189, 284, 299 rat-bite fever 270, 299
pneumonia 146, 164, 173, 189, 190 Reduviidae 13, 60, 241, 243, 292
Index 313
refugees 14, 82, 95, 147, 171, 258 sanitation 42, 5052, 78, 86, 89, 108, 125, 127,
relapsing fever 73, 74, 299 130, 132, 141, 290
endemic, tick borne 260263 incremental 5152, 53
epidemic, louse borne 260 siting and contamination 52
relative risk 28 Sao Paulo fever see Rocky Mountain spotted fever
repellents see vector control methods Sao Tome 139
reservoirs of infection 5, 9 see also Africa
resistance to, infection 1112 sarcocystis 300
insecticides see vector control methods Saudi Arabia 202
respiratory diseases 3, 9, 15, 78, 79, 156168, see also Arabian Peninsular and Asia,
173 Southwest
see also acute respiratory infections scabies 43, 45, 61, 8081, 144, 190, 300
respiratory syncytial virus (RSV) 164, 173, 299 scarlet fever 74, 151, 152, 300
restan 299 see also rheumatic fever and streptococcal
rheumatic fever 77, 151, 176177, 299 infections
see also streptococcal infections schistosomiasis 3, 9, 14, 15, 30, 42, 45, 51, 90,
rhinitis see cold, common 136142, 300
rhinoentomorphthormycosis see Schistosoma haematobium 2, 102, 113, 136139
rhinosporidiosis S. intercalatum 136, 139
rhinospridiosis 299 S. japonicum 113, 136139, 270
Rhodnius 241, 243 S. malayensis 141
rickettsial pox 299 S. mansoni 7, 90, 113, 136139
Rift Valley Fever 20, 201, 202, 288, 299 S. mattheei 141
ringworm see tinea S. mekongi 136, 139
Rio Bravo 299 seasonal/seasonality1519, 21, 89, 90, 97, 98, 149,
Ritters disease see staphylococcal infections 165, 212
river blindness see onchocerciasis Sabethes 206
road-traffic accident 2, 277 Semliki Forest 300
rocio 200202, 299 Senegal 201, 283
Rocky Mountain spotted fever 266, 299 see also Africa
rodents 201, 246, 248, 249, 250, 251, 252, 255, sennetsu fever see ehrlichiosis
261262, 263, 265, 271, 277, 281, 291, sepik 300
292, 293, 294, 295, 296, 299, 302 serial interval 25
see also rats serous meningitis see meningitis, viral
roseola infantum see exanthem subitum serra norte fever 300
Ross River fever 199, 201, 299 serum hepatitis see hepatitis B
rotavirus 77, 89, 90, 299 severe acute respiratory syndrome (SARS) 11, 25,
vaccination 91 73, 173, 285286, 300
see also gastroenteritis sexual reproduction 3, 11, 199, 208209
rubella 74, 149150, 151, 173, 299 sexually transmitted infections (STI) 3, 13, 61, 66,
congenital rubella syndrome 36, 149150 78, 79, 81, 88, 181193, 248, 290
vaccination 36, 150 sheep, diseases associated with 92, 111, 112, 115,
Russia 121, 191, 203, 258, 265, 267, 271, 274, 280, 132, 201, 202, 266, 277, 280, 285, 286,
288, 289 296, 298
Russian springsummer encephalitis 299 shellfish in transmission 93, 101, 109, 110111
Rwanda 230, 258, 285 Shigella 6, 43, 44, 45, 51, 90, 97
see also Africa see also bacillary dysentery
shigellosis see bacillary dysentery
shingles 145, 300
sabia haemorrhagic fever 299 see also chickenpox
St Louis encephalitis 200202, 203, 268, 299 shipyard eye see epidemic keratoconjunctivitis
Salmonella 6, 43, 45, 51, 90, 100, 101, 108, 109, shokwe 300
110, 189, 270, 299 shuni 300
see also food poisoning Siberian tick typhus see tick typhus
Samoa 61 Sierra Leone 283
San Joaquin fever see coccidioidomycosis see also Africa
sand fly fever 300 simian B 300
314 Index
Simulium 15, 42, 228230, 233, 296, 298 Swaziland 191

sindbis 300 see also Africa
Singapore 285286 swineherd disease see leptospirosis
sixth disease see exanthem subitum syphilis, endemic 79, 88, 181, 300
skin infections 42, 43, 78, 79, 8084, 144155 syphilis, venereal 3, 173, 178, 179, 181183, 300
skunk, diseases associated with 271, 282
slave trade, in dissemination of disease 14,
129130, 139 T-cell leukaemia/lymphosarcoma 300
sleeping sickness 3, 9, 11, 14, 22, 42, 45, 57, 68, tacaiuma 300
74, 234241, 300 Taenia 6, 9, 10, 42, 43, 44, 51, 113, 119121, 300
see also Trypanosoma tahyna 300
small round structured virus (SRSV) Taiwan 112, 116, 117, 139
see Norwalk see also Asia
smallpox 26, 68, 73, 74, 145, 284, 287, 288, 300 tamdy 300
snail, as intermediate host 9, 137138, 141 Tanzania 14, 18, 147, 154, 230, 236
diseases from eating slugs and 291, 293 see also Africa
fever see schistosomiasis tapeworm, beef see Taenia
snowshoe hare encephalitis 300 tapeworm, fish see Diphyllobothrium
sodoku see rat-bite fever tapeworm, pig see Taenia
soft chancre see chancroid tataguine 300
soil contact diseases 42, 43, 78, 79, 88, 124135 temephos 5657, 82
soil eating see pica temperature 15, 139
Solomon Islands 19, 208 tensaw 300
see also Pacific Islands tetanus 3, 5, 69, 74, 132135, 272, 301
South Africa 165, 191, 193 neonatal 35, 69, 132135
South American blastomycosis see vaccination 35, 37, 133, 134, 135
paracoccidioidiomycosis Thailand 95, 112, 116, 117, 161, 192, 203, 222,
sparganosis 300 258, 276
spirillosis see rat-bite fever see also Asia
spondweni 300 thogoto 301
sporotrichosis 300 three pot system 50
Sri Lanka 211, 222 threadworm see Enterobius
see also Asia thrush see candidiasis
Staphylococcus 88, 90, 108, 109, 110, 173, 175, tick typhus/fever 265266, 301
300 tickborne meningopolyneuritis see lyme
see also food poisoning and otitis media disease
streptobacillary fever see rat-bite fever ticks 9, 60, 201, 261268, 270, 288, 289, 290,
streptococcal infections 22, 77, 159, 173, 176, 177 293, 294, 295, 296, 297, 299, 300, 301, 302
sepsis of the newborn 300 control of see ectoparasite control
skin infection 83, 88, 151152 hard 263268
sore throat 300 infections transmitted by 77, 260268
see also impetigo, rheumatic fever and soft 261263
scarlet fever Timorean filariasis see filariasis, lymphatic
Streptococcus pneumoniae 164, 172174, 175 tinea 43, 45, 8283, 270, 301
vaccination 166, 174, 175 Tioman virus 288
Strongyloides 6, 42, 51, 123, 130132, 190, tonate 301
270, 300 torula see cryptococcosis
subacute spongiform encephalopathy see toscana 301
Creutzfeld-Jakob disease toxic shock syndrome 301
subclinical transmission 1011, 93, 101, 105 see also staphylococcal and streptococcal
Sudan 142, 143, 196, 230, 246, 278 infections
see also Africa Toxocara 45, 270, 275, 301
surveillance 6668, 69, 73, 74 toxoplasmosis 2, 45, 123, 190, 276277, 301
active 6667, 71 trachoma 3, 15, 43, 45, 51, 61, 69, 8486, 301
emergency 67 transmissible spongiform encephalopathy 285
passive or routine 66, 71 transmission cycles 8
sentinel 67, 167 travellers health 14, 98, 102, 111
Index 315
treatment centres 64, 96, 97, 171 vaccination 32, 3440, 290
treatment schedules 64 cold chain 3738
trench fever 301 economies of 13, 3839
Triatoma 241, 243 requirements, international 7476
trichinosis (trichinellosis) or Trichinella 44, ring 38, 208
121122, 301 schedule 3537
Trichomonas 185, 186, 301 static clinics in 38
trichophytosis see tinea see also under each vaccinatable disease
Trichuris 3, 5, 43, 44, 45, 51, 113, 123, 124125, vaccine 3435, 218
127, 301 efficacy 3940
Trinidad 201 valley fever see coccidioidomycosis
see also Caribbean varicella see chickenpox
trivittatus 301 vector-borne diseases 198268
tropical bubo see lymphogranuloma venereum vector control, biological 57, 141, 217, 290
tropical spastic paresis 301 deterrents and repellents 5556, 77,
tropical ulcer 8384, 144, 301 202, 203, 233, 248, 252, 258, 265,
trubanaman 301 266
Trypanasoma brucei brucei 234 environmental modification 57, 58, 59, 141,
T. b. gambiense 234237, 238, 240 204205, 238239, 248
T. b. rhodesiense 234236, 237238, insecticides 5255, 5761, 201, 217, 225,
240, 241 248, 252, 258, 264265, 266
T. cruzi 241 larvicides and larval control 5657,
trypanosomiasis, African see sleeping sickness 204205, 208, 217, 225, 230
American see Chagas disease methods 34, 5261, 77
tsetse fly 14, 42, 235, 236, 237, 238239 personal protection 202, 203, 216, 233, 252,
see also Glossina 258, 265
tsutsugamushi diseases see typhus, scrub see also mosquito nets
tuberculosis 3, 11, 12, 61, 74, 78, 127, 154, 155, vegetables, diseases transmitted by 99, 104, 123,
156164, 189, 190, 275, 301 125, 126, 132, 289, 294
vaccination 36, 161162 see also plants in disease transmission and
see also BCG and Mycobacterium soil contact diseases
tuberculosis Venezuela 230, 242
tucunduba encephalitis 301 see also America, South
tularaemia 270, 289, 301 Venezuelan equine encephalitis 200202, 302
Tunga 301 Venezuelan haemorrhagic fever see guanarito
Turkey 211 haemorrhagic fever
see also Asia, Central verruca see warts
typhoid 7, 10, 42, 43, 44, 45, 51, 63, 64, 73, 74, verruga peruana see bartonellosis
100103, 123, 144, 301 vesicular pharyngitis, enteroviral see
vaccination 102 herpangina
typhus 74, 254260, 301 vesicular rickettsiosis see rickettsialpox
epidemic louseborne 42, 60, 73, 254255, vesicular stomatitis fever 302
257258, 301 Vibrio cholerae 6, 7, 92
murine, fleaborne 254255, 257, 301 V. cholerae 01 92
recurrent 258 V. cholerae 0139 92
scrub, miteborne 9, 14, 73, 254257, 302 V. parahaemolyticus 90, 108, 109
see also cholera
vibrionic enteritis see campylobacter
Uganda 154, 192, 196, 201, 230, 285 Vietnam 79, 105, 117, 203, 222, 252, 285
see also Africa see also Asia
ulcus molle see chancroid viral carditis see enteroviral carditis
undulant fever see brucellosis viral diarrhoea see Norwalk
Uruguay 242
uruma fever see mayaro fever
USA 174, 200, 201, 204, 266, 274, 288, 289 wanowrie 302
usutu 302 warts, genital see human papillomavirus
uta see leishmaniasis, mucocutaneous skin 302
316 Index
water, diseases related to 41, 42, 78, 89, 111, 291, Xenopsylla 250252, 254, 256, 257, 298, 301
298, 299, 300, 301, 302 xingu fever 302
based diseases 42, 43, 89106, 295
contact, diseases of 78, 136143, 300
washed diseases 41, 42, 43, 78, 8088 yaws 12, 43, 45, 68, 71, 83, 88, 178179, 302
water supplies 4350, 78, 86, 89, 98, 233, 290 yellow fever 9, 10, 14, 20, 73, 74, 201, 202,
capacity 46 206208, 302
economic criteria 4546 vaccination 74, 208
rain catchment 46, 48 zones 7576
sources 4649 Yemen 139, 202, 229, 230
water-buffalo, diseases associated with 142, 281 see also Arabian Peninsula and Asia,
Weils disease see leptospirosis Southwest
wesselsbron 302 yersiniosis 302
West Nile fever 199200, 201, 203, 288, 302
western equine encephalitis 200202, 268, 302
whip worm see Trichuris Zaire see Congo
Whitmore disease see melioidosis Zambia 193, 285
whooping cough 3, 14, 73, 74, 159, 167168, 298 see also Africa
vaccination 34, 35, 166, 168 Zanzibar 227
Widal test 101 see also Tanzania
winter vomiting disease see Norwalk zika 302
wolves and rabies 271, 273 Zimbabwe 191, 196
wolynian fever see trench fever see also Africa
woolsorters disease see anthrax zoonosis 910, 78, 79, 249283
Wuchereria bancrofti 5, 52, 219, 221, 222, 223, zygomycosis see mucormycosis
224, 225226
wyeomyia 302

Communicable Disease Epidemiology and Control A Global Perspective

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Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.

2004 4:56am page i

Communicable Disease Epidemiology and Control

This book is dedicated to Michael Colbourne (19191993), malariologist, teacher and

CABI Publishing is a division of CAB International

CABI Publishing CABI Publishing

Library of Congress Cataloging-in-Publication Data

ISBN 0 85199 902 6

Typeset by Kolam Information Services Pvt. Ltd, Pondicherry, India

1 Elements of Communicable Diseases 1

2 Communicable Disease Theory 21

3 Control Principles and Methods 32

4 Control Strategy and Organization 62

4.3 Control and Eradication 68

5 Notification and Health Regulations 73

5.1 International Health Regulations 73

6 Classification of Communicable Diseases 77

9 Food-borne Diseases 108

9.1 Food Poisoning 108

9.9 Trichinosis 121

10 Diseases of Soil Contact 124

10.1 Trichuris (Whip Worm) 124

11 Diseases of Water Contact 136

11.1 Schistosomiasis 136

12 Skin Infections 144

12.1 Chickenpox/Shingles (Varicella) 144

13 Respiratory Diseases and Other Airborne Transmitted Infections 156

13.1 Tuberculosis 156

14 Diseases Transmitted Via Body Fluids 178

14.1 Yaws 178

14.10 Genital Herpes 188

15 Insect-borne Diseases 198

15.1 Mosquito-borne Diseases 198

16 Ectoparasite Zoonoses 249

16.1 Plague 249

17 Domestic and Synanthropic Zoonoses 269

17.1 Rabies 269

18 New and Potential Diseases 284

18.1 The Animal Connection 284

19 List of Communicable Diseases 290

1.1 What are Communicable Diseases? tries and non-communicable in the

Elements of Communicable Diseases 3

DALYsa (000s) Mortality (000s)

Disease Total Females Total Females

Lower respiratory infections 90,748 42,846 3,871 1,856

exact replicas are produced, so that any nat-

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof

Virulence Toxicity Carriers Immunity

25.10.2004 12:34pm page 4

Fig. 1.1. Agent, transmission, host and environment.

Elements of Communicable Diseases 5

1 day 1 week 1 month 1 year

Elements of Communicable Diseases 7

Human Human Human

Animal Animal Arthropod Arthropod

Animal Animal Arthropod Arthropod

Insect Insect Human Human

Fig. 1.3. Transmission cycles.

Elements of Communicable Diseases 9

1.3.1 Direct occur due to the feeding of the arthropod or

(Snails, especially in descriptions of schis-

Elements of Communicable Diseases 11

Pregnancy When a woman is pregnant, her