NUR 3209

PRINCIPLES OF EPIDEMIOLOGY

STRATEGIES OF EPIDEMIOLOGY

Disease Causation Pattern

The science of epidemiology draws on certain basic concepts and principles to analyze and understand
patterns of occurrence among aggregate health conditions. Through their early study of infectious
diseases, epidemiologists began to consider disease states generally in terms of the epidemiologic triad,
or the host, agent, and environment model. Interactions among these three elements explained infectious
and other disease patterns.

HOST
The host is a susceptible human or animal who harbors and nourishes a disease-causing agent. Many
physical, psychological, and lifestyle factors influence the host’s susceptibility and response to an agent.
Physical factors include age, sex, race, and genetic influences on the host’s vulnerability or
resistance.
Psychological factors, such as outlook and response to stress, can strongly influence host
susceptibility.
Lifestyle factors also play a major role. Diet, exercise, sleep patterns, and healthy or unhealthy
habits all contribute to either increased or decreased vulnerability to the disease causing agent.
The concept of resistance is important for public health nursing practice. People sometimes have an
ability to resist pathogens. This is called inherent resistance. Typically, these people have inherited or
acquired characteristics, such as the various factors mentioned earlier, that make them less vulnerable.
.
AGENT
An agent is a factor that causes or contributes to a health problem or condition. Causative agents can be
factors that are present (e.g., bacteria that cause tuberculosis, rocks on a mountain road that contribute to
an automobile crash) or factors that are lacking (e.g., a low serum iron level that causes anemia or the
lack of seat belt use that contributes to the extent of injury during an automobile crash). Agents vary
considerably and include five types: biologic, chemical, nutrient, physical, and psychological.
Biologic agents include bacteria, viruses, fungi, protozoa, worms, and insects. Some biologic agents are
infectious, such as influenza virus or HIV.

1
Chemical agents may be in the form of liquids, solids, gases, dusts, or fumes. Examples are poisonous
sprays used on garden pests and industrial chemical wastes. The degree of toxicity of the chemical agent
influences its impact on health.
Nutrient agents include essential dietary components that can produce illness conditions if they are
deficient or are taken in excess. For example, a deficiency of niacin can cause pellagra, and
too much vitamin A can be toxic.
Physical agents include anything mechanical (e.g., chainsaw, automobile), material (rock slide),
atmospheric (ultraviolet radiation), geologic (earthquake), or genetically transmitted that causes injury to
humans. The shape, size, and force of physical agents influence the degree of harm to the host.
Psychological agents are events that produce stress leading to health problems.

Agents may also be classified as infectious or noninfectious.

Infectious agents cause communicable diseases, such as AIDS or tuberculosis—that is, the disease can be
spread from one person to another. Certain characteristics of infectious agents are important for
community health nurses to understand.
Extent of exposure to the agent, the agent’s pathogenicity (capacity to cause disease in the host), its
infectivity (capacity to enter the host and multiply), its virulence (severity of disease), toxigenicity
(capacity to produce a toxin or poison), resistance (ability of the agent to survive environmental
conditions), antigenicity (ability to induce an antibody response in the host) and its structure and
chemical composition all influence the effect of the agent on the host.
Noninfectious agents have similar characteristics in that their relative abilities to harm the host vary with
type of agent and intensity and duration of exposure.

ENVIRONMENT
The environment refers to all the external factors surrounding the host that might influence vulnerability
or resistance. The physical environment includes factors such as geography, climate and weather, safety
of buildings, water and food supply, and presence of animals, plants, insects, and microorganisms that
have the capacity to serve as reservoirs (storage sites for disease-causing agents) or vectors (carriers) for
transmitting disease. The psychosocial environment refers to social, cultural, economic, and
psychological influences and conditions that affect health, such as access to health care, cultural health
practices, poverty, and work stressors, which can all contribute to disease or health.

2
HOST-AGENT-ENVIROMENT MODEL

CAUSALITY
This refers to the relationship between a cause and its effect. A purpose of epidemiologic study has been
to discover causal relationships to understand why conditions develop and offer effective prevention and
protection. As scientific knowledge of health and disease has expanded, epidemiology has changed its
view of causality.

Chain of Causation
As the scientific community’s thinking about disease causation and the tripartite model (host-agent-
environment) grew more complex, epidemiologists began to use the idea of a chain of causation. The
chain begins by identifying the reservoir (i.e., where the causal agent can live and multiply). With
malaria, infected humans are the major reservoir for the parasitic agents, although certain nonhuman
primates also act as reservoirs. Next, the agent must have a portal of exit from the reservoir, as well as
some mode of transmission. For example, the bite of an Anopheles mosquito provides a portal of exit for
the malaria parasites, which spend part of their life cycle in the mosquito’s body; the mosquito in this case
is the mode of transmission. The next link in the chain of causation is the agent itself. Malaria, for
example, actually consists of four distinct diseases caused by four kinds of microscopic protozoa. The
next link is the portal of entry. In the case of malaria, the mosquito bite provides a portal of exit as well as
a portal of entry into the human host.

3
 CHAIN OF CAUSATION

As described above, the traditional epidemiologic triad model holds that infectious diseases result from
the interaction of agent, host, and environment. More specifically, transmission occurs when the agent
leaves its reservoir or host through a portal of exit, is conveyed by some mode of transmission, and
enters through an appropriate portal of entry to infect a susceptible host. This sequence is sometimes
called the chain of infection.
Components of communicable diseases are links of a chain or factors that are essential to the
development of the infectious agent and propagation of disease. Components involved in the chain of
communicable disease transmission are:
a. Infectious agent
b. Reservoir
c. Portal of exit
d. Mode of transmission
e. Portal of entry
f. Susceptible host