EPiDEMiOLOGiCAL

TRANSiTiON

Any major shift in patterns of disease or

causes of death that affects the level and
character of mortality in a population

Dr. Manju
JR, Community Medicine
PGIMS, Rohtak
Contents
 Health transition
 Demographic transition
 Epidemiological transition
 Three stages of epidemiological transition
 Exception and Implication of epidemiological transition
 Hybristic Stages
 Future stages of epidemiological transition
 Epidemiological transition in developed and developing countries
 Epidemiological transition models
 Critics
 Conclusion
The Health Transition
 Health transition: the shifts that have taken place in the
patterns and causes of death.

 The health transition has been covered by two separate

terms:

 Demographic transition
 Epidemiological transition
Demographic Transition
 A change in the population dynamics of a country as it
moves from

HIGH FERTILITY AND MORTALITY RATES

LOW FERTILITY AND MORTALITY RATES

Demographic Transition Model
This model
- isishighly
basedpredictive
on the interpretation
Attitudes change
for most of demographic history
&rate
countries
Crude birth/death
Crude high
birth/death ratesThompson
low PHASE 1
developed in 1929 byHigher
the American demographer
standards of
Fragile, butPopulation
Warren
stable, population
stable
. PHASE 3
2
4
living/education
Populations aging

Crude birth rate finally falls

Population growth is slow

improved agriculture and

medicine Lower death rates
not accompanied by a parallel
reduction in birth rate
Natural increase very high
Demographic Transition
DEVELOPED VS. DEVELOPING NATIONS
 All industrialized nations have gone through these phases
of demographic transition.

 The developing nations have completed Phase I and are

currently in Phase II - a phase of explosive rates of natural
increase.

 Countries in western Europe took roughly 200 years to

complete their transitions.
Epidemiologic Transition

A characteristic shift in the disease pattern of a

population as mortality falls during the demographic
transition: acute, infectious diseases are reduced,
while chronic, degenerative diseases increase in
prominence, causing a gradual shift in the age pattern
of mortality from younger to older ages.

(Omran 1970)
 Demographic and
Epidemiologic transition
Economic,
social &  nutrition  mortality
Industrialization  public
environ  ( infant mortality)
& urbanization sanitation,
mental technology  life expectancy
housing,
changes for health
health care
care
  fertility
 per cap. income,
 wealth

 levels of RF:  NCD  persons at Increasing

fat, calories, tobacco, risk of aging
 infectious
sedentary habits developing
diseases population
NCDs

IUMSP-GCT
Epidemiologic Transition Theory
 Formulated by epidemiologist Abdel Omran in 1971.
 It comprises three stages characterized by fertility
levels and causes of death

1. The age of pestilence and famine

2. The age of receding pandemics
3. The age of chronic diseases
Life Improved medical
expectancy care and social Healt
determinants h
influences health
Increased economic growth
improves use of ecological
resources and provides Health
basic social services Age of chronic
diseases

Poor use of
ecological resources
and lack of social and
Age of receding pandemics
economic capital
h
Health

Age of pestilence and

famine Time
First Epidemiological Transition
 The First Epidemiological
Transition occurred 100
centuries ago when man
moved towards the
agricultural society.
 By eschewing the nomadic
lifestyle, people stayed in
one place and increased
their contact with human
(and animal) waste, and
contaminated their water
supplies.
First Epidemiological Transition…
 And even the cultivation of
soil, and the clearing of land,
exposed people to insect
bites, bacteria, and parasites.

 As cities grew, and

exploration of the
surrounding world increased,
man spread deadly diseases
in ever-greater numbers.
First Epidemiological Transition…..
 This epidemiological transition
was described as
“the age pestilence and famine"
.

 Epidemic, famines and wars

caused huge numbers of deaths.

 Infectious diseases were

dominant, causing high mortality
rates, especially among children.
First Epidemiological Transition…
 The domestication of animals
brought other disease vectors in
close contact with humans.
Q Fever, Anthrax, tuberculosis
gained access to human hosts.
 While increasing food security
and nutrition, this transition also
introduced several significant
disease factors.
Small pox, Cholera, plague, influenza, and typhus all
became major scourges for humanity.
First Epidemiological Transition….
 Small pox : 12,000 Years of
Terror
 It first appeared in agricultural
settlements in north-eastern
Africa around 10,000 B.C.
 Egyptian merchants spread it
from Africa to India.
 In Europe, near the end of the
eighteenth century, the disease
accounted for nearly 400,000
deaths each year.
First Epidemiological Transition….
 Of those surviving, one-
third were blinded.

 The worldwide death toll

was staggering and
continued well into the
twentieth century, where
mortality has been
estimated at 300 to 500
million.
First Epidemiological Transition…
 Plague – The Black Death.
 The first recorded case of the plague
was in China in 224 B.C.
 But the most significant outbreak was
in Europe in the mid-fourteenth century.
 Over a five-year period from 1347 to
1352, 25 million people died.
 One-third to one-half of the
European population was wiped out
!!!!!!
First Epidemiological Transition
 Cholera
 The major cholera pandemics
are generally listed as:
 First: 1817-1823,
 Second: 1829-1851,
 Third: 1852-1859,
 Fourth: 1863-1879,
 Fifth: 1881-1896,
 Sixth: 1899-1923,
 Seventh: 1961- 1970,
First Epidemiological Transition….
 High levels of mortality and fertility.

 Crude Death Rate (CDR) is high and ranges from 30 to

over 50 deaths per 1,000 population.

 Infant mortality rate 200-300 deaths per 1,000 live

births.

 Life expectancy between 20-40 years.

First Epidemiological Transition….
 The provision of basic ecological resources, i.e. food and
fresh water, was inadequate.

 There was lack of sufficient infrastructure for most

services.

 Population growth, improvements in health, and

advances in socio-economic development were all
limited by the local carrying capacity of the environment.
First Epidemiological Transition…..
 In this stage, women of
childbearing age also
faced considerable risks
due to the complications
associated with
pregnancy and childbirth.
 Some developing
countries are still in this
stage.
Second Epidemiological Transition
 The Second Epidemiological
Transition began roughly 200
years ago, with the Industrial
revolution.
 While many of the existing
diseases brought forth during the
first transition certainly did not go
away, new-chronic, non-
infectious, degenerative
diseases – were added to the
mix.
Second Epidemiological Transition
 This phase was described as
“age of receding pandemics” by Omran.
 It involved a reduction in the prevalence of infectious
diseases, and a fall in mortality rates.
 CDR reaches a level of less than 30 deaths per 1,000
population.
 IMR was 150 per 1,000 live births.
 As a consequence, life expectancy at birth climbed
rapidly from about 35 to 50 years.
Second Epidemiological Transition
 Increased economic growth led to a
sharp fall in deaths from infectious
diseases, and from malnutrition.
 This Improvement occurred before
effective medical treatment and was
due to impact of following
interventions:
 clean water
 sanitary sewage
 mosquito suppression (malaria/yellow
fever)
 increased food safety – refrigeration and
pasteurization
 increased pre & post-natal care
Second Epidemiological Transition
Second Epidemiological Transition
Second Epidemiological Transition
 Finally, the introduction of modern healthcare and health
technologies, e.g.
 immunization programmes
 introduction of antibiotics

enabled the control and elimination of group of infectious

diseases such as Diphtheria, polio and smallpox.
Second Epidemiological Transition
Second Epidemiological Transition
 Technology also brought with it
smokestack industries, chemical
toxins, working indoors, stress,
greater access to less `healthful’
food; beside advances in medicine
and sanitation.
 And with this second transition we’ve
seen rises in allergies, asthma,
autoimmune disorders, and sexually
transmitted diseases as well.
Second Epidemiological Transition
 As fertility rates were high, population was growing
rapidly at this stage of the health transition. Without
moving to the next stage, the carrying capacity of the
local ecosystem may be exceeded.
 As population and ecological pressures increased, food
and water became scarcer, and the lack of ecological
and social resources may cause economic
development to stagnate.
 If there is a surplus of available resources, the
transition may be accelerated, but if they are lacking, the
transition may slow, or even stagnate in this phase.
Third Epidemiological Transition
 Began in the late 20th century.
 This phase was described as
 ‘The age of chronic diseases’
by Omran.
 In the third stage the elimination of
infectious diseases makes way for
chronic diseases among the elderly.
 The major causes of death are so-
called chronic degenerative and man-
made diseases such as cardiovascular
diseases, cancer, and diabetes.
 Infectious Diseases

NIDDM CHD
Trauma
CA
Mortality Rates

Epidemiologic Transition
Third Epidemiological Transition
Third Epidemiological Transition
 While improved healthcare means
that these are less lethal than
infectious diseases, they
nonetheless cause relatively high
levels of morbidity.

 Increasingly, health patterns depend

on social and cultural behaviour,
such as patterns of food
consumption and drinking
behaviour.
Third Epidemiological Transition
 Due to low levels of mortality and fertility, there is
little population growth.
 CDR stabilises at a level of less than 20 deaths per
1,000 population.
 By the end of the third stage, infant mortality reaches a
level of less than 25 deaths per 1,000 live births.
 When the health transition is at an advanced stage, life
expectancy may exceed 80 years.
 However, the prevalence of one or more diseases
means that such a long life also includes, on average, a
relatively long period of morbidity.
Third Epidemiological Transition
 This stage occurs at different rates in different nations:
 in both developed and developing countries, mortality
rates are driven by socially determined factors;
 in developed nations they are also driven by medical
technology.

 It becomes necessary to ensure sufficient social and

health-care investment for all age groups.

 At the same time, there is increased demand for

healthcare related to the diseases of older people.
Aging populations
1950 1975 2000 2025 Increase
(fold)
trends in number of persons (millions) aged 60
1950-2025
Brazil 2 6 14 32 15
Mexico 1 3 7 18 13
Nigeria 1 3 6 16 12
Indonesia 4 7 15 31 8
China 42 74 135 284 7
Bangladesh 3 3 7 17 6
Japan 6 13 26 33 6
India 32 30 66 146 5
USSR 16 34 54 71 4
USA 19 32 40 67 4
Italy 6 10 14 16 3
Germany 7 12 13 15 2
Exceptions

 Though the struggle against infectious diseases, especially

tropical diseases, was at first successful, some countries,
mainly in Africa, were unable to reach a pace of
progress sufficient to reduce the gap separating them
from developed countries.

 The arrival of AIDS often caused severe reversals and

towards the end of the 1980s, life expectancy levels
suddenly dropped.
Implications of Epidemiological
Transition
 The epidemiologic transition have given rise to as many
problems which include:

 nuclearization of the family

 the destruction of group cohesion
 rise in mental illness
 crime, delinquency
 drug dependency which boost the demand/psychiatric
help
 alarming rise in medical costs
Hybristic Stage
 Rogers and Hackenberg (1987) felt that the original theory
lacked reference to violent and accidental deaths and
deaths due to behavioural causes.
 They proposed a fourth stage that they called the
hybristic stage.
 The term ‘hybris’ refers to excessive self-confidence or a
belief of invincibility.
 During the hybristic stage, morbidity and mortality are
affected by man-made diseases, individual behaviours,
and potentially destructive lifestyles.
Hybristic Stage
 Rogers and Hackenberg (1987) further remarked that while
most environmentally-based infectious diseases are
eradicated during the hybristic stage, some infectious
diseases are increasing in importance due to individual
lifestyles and man-made causes.

 A well-known example of such an infectious disease is

HIV/AIDS.
Future stages of the epidemiological transition

 Martens (2002) described the developments in the

health status of populations according to three potential
future 'ages‘ :

4. “the age of emerging infectious diseases”

5. “the age of medical technology”
6. “the age of sustained health”

 These stages are imaginary (although some features are

already recognizable in some countries) and are not
sharply delineated- there is always a continuum.
 Health

Age of sustaining health

Health

Age of medical
technology
Health

Age of emerging infectious diseases

The age of emerging infectious diseases

 In this stage, the emergence of new infectious

diseases or the re-emergence of 'old' ones
will have a significant impact on health.
 A number of factors will influence this
development:
 travel and trade
 microbiological resistance
 human behaviour
 breakdowns in health systems
 increased pressure on the environment
The age of emerging infectious diseases

 Social, political and economic

factors that cause the
movement of people will
increase contact between
people and microbes.

 Environmental changes caused

by human activity (for example,
dam and road building,
deforestation, irrigation, and,
at the global level, climate
change) will all contribute to
the further spread of disease.
The age of emerging infectious diseases

 The overuse of antibiotics and insecticides,

combined with inadequate or deteriorating public
health infrastructures will hamper or delay responses
to increasing disease threats.

 As a result, infectious diseases will increase

drastically, and life expectancy will fall.
The age of emerging infectious diseases

 Ill health will lead to lower levels of economic activity,

and poor countries will be caught in a downward
spiral of depressed incomes and bad health.

 Control of infectious diseases will be hampered by

political and financial obstacles, and by an inability to
use existing technologies.
The age of medical technology
 To a large extent, increased health risks caused by
changes in life-style and environmental changes will be
offset by increased economic growth and
technology improvements in the age of medical
technology.

 If there is no long-term, sustainable economic

development, increased environmental pressure and
social imbalance may propel poor societies into the age
of emerging infectious diseases.
The age of sustained health
 In the age of sustained health, investments in social
services will lead to a sharp reduction in life-style
related diseases, and most environmentally related
infectious diseases will be eradicated.

 Health policies will be designed to improve the health

status of a population in such a way that the health of
future generations is not compromised by, for example,
the depletion of resources needed by future generations.
The age of sustained health
 Although there is only a minimal chance that infections
will emerge, improved worldwide surveillance and
monitoring systems will mean that any outbreak is
properly dealt with.

 Despite the ageing of the world population, health

systems will be well adjusted to an older population.

 Furthermore, disparities in health between rich and poor

countries will eventually disappear.
Epidemiological Transition – Developed Countries

 Currently, most developed countries are in the third

stage of the health transition:

 fertility rates are low

 causes of diseases and deaths have shifted from

infectious to chronic diseases.
Epidemiological Transition – Developed Countries

 All developed countries in Europe, North America and

Asia are seen as having arrived in the latter stage of the
health transition in the 1970s, although there were
large differences with regard to timing, particularly in
the onset of the decline in fertility.

 In these countries, declining fertility rates and

increased life expectancy have led to the ageing, or
so-called 'greying', of the population.
Epidemiological Transition –Developing Countries

 The health situation in

developing countries
varies greatly from one
country to another.

 In most, there is still very

low life expectancy; this
is due largely to
malnutrition and the lack
of safe drinking water,
which are compounded by
poor healthcare
facilities.
Epidemiological Transition –Developing Countries

 In other countries, particularly in Asia and Latin America,

chronic diseases have now become more important
than infectious diseases.

 In countries such as China and Thailand fertility rates

are very low; in others they are very high.

 Due to sub-national differences of an economic, social or

ecological nature, there may also be large differences
within a single country.
Epidemiological Transition –Developing Countries

 It is widely believed that, with increasing economic

growth, developing countries will follow the same pattern
of health transition as Europe and North America.

 However, there is now evidence that the poorest in

developing countries will not 'trade' infectious diseases
for chronic diseases; instead, they face a triple
burden of communicable disease, non-communicable
disease and socio-behavioural illness.
 Transition Stages in the developing Countries
< 20th/Early 20th Century 1940-1960/70 1960/70-2050+
TRIPLE HEALTH
BURDEN
Unfinished old set
Old set of morbidity Communicable disease
Reproductive morbidity
-Communicable disease Rapid change Nutritional deficiency
* epidemics since mid 20th
Rapid population growth
* endemic Century
-Reproductive morbidity Rising new set
and mortality Cardiovascular disease
- Nutritional deficiency Transition Malignancy and diabetes
Stress (depression)
-Poor sanitation and Ageing and diseases of the elderly
housing
-Poor personal hygiene Transition Accidents (traffic, work)
Emerging and resurgent diseases
-High child mortality
-High disability Adjusted Lagging health care
Health systems and medical
Life years Lost (DALYS) Recession of training ill-suited for the rising
due to early death epidemics chronic and continuing acute
-Poverty diseases plus long-term care for
the aged, the disabled and the
Preventable disease mentally ill.
burden
LE 30 30-45 45-70 +
Epidemiological Transition –Developing Countries

 Although improvements in health may take place

worldwide, differences in health status between the
developing and developed world will to some extent
remain, regardless of the future development path.

 The processes of globalization in today's world that

include socio-economic change, demographic change
and global environmental change, oblige us to broaden
our conception of the determinants of population
health.
Epidemiological Transition model
 Countries and regions have shown differences in passing
through the above-mentioned stages , with regard to
timing, pace, and underlying mechanisms.
 Therefore, Omran (1971, 1982) proposed several basic
models of the epidemiologic transition.
 Initially, he proposed three models, but later added a fourth
variant.
The Classical Model of Epidemiological Transition

 In Western European countries.

 The mortality pattern follows three stages.
 A pre-industrial age of pestilence and famine generates a
cyclical population growth with frequent peaks in mortality
is followed by an intermediate stage of receding pandemics
in the middle or later part of the 19th Century giving way to
a gradual mortality decline.
 A stage of degenerative and man made diseases in
the 20th Century corresponds to more precipitous declines.
The Classical Model of Epidemiological Transition

 Economic factors (improvements in standards of living

and in nutrition in the 19th Century) were the primary
determinants of the classical transition, but were later
augmented in the 20th Century by sanitary
improvements, followed by medical and public health
progress.
The Accelerated Model
 Observed in Japan and Eastern Europe.
 The transition follows a similar pattern as the Classical
Model, but mortality decline started later and reached the
low level in a shorter period of time.
 The changes were based on general social improvements
(for example in nutrition) as well as sanitary and medical
advances.
The Delayed Epidemiological Transition

 most countries in Africa, Latin America, and Asia.

 Mortality drops in these countries have mainly been
achieved by the application of modern medical technology.
 Though initially mortality decline was fast, it slowed down
after the 1960s, especially in terms of infant and child
mortality.
 The Epidemiological Transition closely parallels the
demographic transition and Industrial Revolution and is
therefore followed by a population explosion and by
sustained economic growth.
Transitional Variant Of The Delayed Model

 This model depicts the transition in a number of

developing countries such as Taiwan, South Korea,
Singapore, Hong Kong, Sri Lanka, Mauritius, and
Jamaica.
 In these countries, the rapid decline in mortality in the
1940s was comparable to that in countries matching the
delayed model.
 However, the decline did not slacken to the same
extent.
 Protracted-polarised Model
 Suggested by Frenk, Bobadilla and colleagues (Frenk et al.
1989a, 1989b; Bobadilla et al. 1993)
 This variant of the transition reflects the experiences of
some large middle-income countries such as Mexico.
 The transition in these countries is to an extent
characterised by a relatively fast mortality decline that
started in the 20th century.
 First of all, incidences of non communicable disease
increase before infectious diseases are fully brought under
control.
 Protracted-polarised Model
 This results in a so-called overlap of eras.

 Further, some epidemic diseases that were controlled or

even eradicated re-emerge and lead to a counter
transition.

 For instance, malaria, dengue fever, and cholera have re-

emerged in Mexico (Bobadilla et al. 1993).
 Protracted-polarised Model
 Lastly, unequal distributions of wealth and health services
lead to increasing differences and widening gaps between
social classes and between geographical regions

 This process has been described as epidemiologic

polarisation.

 Examples of countries with important differences in

mortality between geographic regions include Mexico and
India.
 CRiTiCS
 Mackenbach (1994) limited his comments to the Western
model of the transition. He argues that the concept of the
epidemiologic transition is ill-defined and ambiguous.

 In his argument, he focuses in particular on the difficulties

related to the identification and location in time of both the
beginning and the end of the transition.
 CRiTiCS
 Frenk et al. and Smallman-Raynor and Phillips put their
emphasis on the notion of reversibility and warn against
the assumptions of an unidirectional sequence and
uninterrupted progression.

 From this perspective, the re-emergence of infectious and

parasitic diseases in developed countries would not
indicate a fifth stage but rather a possible counter-
transition.
 CRiTiCS
 By presenting their protracted-polarised model, Frenk,
Bobadilla and colleagues challenged the notion that “all
countries eventually pass through the same stages of the
transition, and that in each stage there is one dominant
pattern of morbidity and mortality”.

 They tried to overcome this weakness in the transition

theory by introducing the concepts of counter transition,
overlap of eras, and epidemiologic polarisation.
 CRiTiCS
 Gaylin and Kates (1997) feel that the generalisability of the
epidemiologic transition theory may be undermined by the large
differences in mortality trends among population subgroups.
 As a result, they argue for “the need to ‘particularise’ the focus
of the epidemiologic transition on population subgroups”.
 In addition, they argue that the epidemiologic transition theory
suggests “a level of control of infectious diseases that has not
been achieved among certain subgroups and, in some cases,
entire populations”.
 In other words, the theory is believed to have overestimated the
decline in infectious diseases as a cause of death.
Conclusion
 Nevertheless, it is generally believed that the epidemiologic
transition theory presents a broad conceptual framework
that is useful for the study of global trends in disease and
mortality.

 “the epidemiologic transition theory provides a potentially

powerful framework for the study of disease and mortality
in populations, especially for the study of historical and
international variations”. Mackenbach (1994)
Conclusion
 This framework can be used to speculate on the possible
consequences of future changes in countries that have not
yet completed the epidemiologic transition.
 These perceptions suggest what is perhaps the best way
to view the ‘epidemiologic transition’: not as a theory, but
rather as a framework or perspective.
References
 Early life changes e-book.
 National institute of demography, Paris, France.
 Lecture by Dr. SC Mathur