Epidemiology

and Prevention

Epidemiology CHS234
Natural history of disease

– Natural history of disease refers to "the progression of a

disease process in an individual over time, in the absence of
intervention".
– Many, if not most, diseases have a characteristic natural
history, although the time frame and specific manifestations
of disease may vary from individual to individual and are
influenced by preventive and therapeutic measures.
Stages in the natural history of a
disease
1. Stage of susceptibility:
The disease has not yet developed, but the presence
of risk factors that favor its occurrence.
2. Stage of pre-symptomatic (sub-clinical) disease:
• The process begins with the appropriate exposure (or
accumulation of factors) sufficient for the disease
process to begin in a susceptible host.

• For an infectious disease, the exposure is a

microorganism. For cancer, the exposure may be a
factor that initiates the process, such as asbestos
fibers or components in tobacco smoke (for lung
cancer), or one that promotes the process, such as
estrogen (for endometrial cancer).
• After the disease process has been triggered, pathological
changes then occur without the individual being aware of
them. This stage of subclinical disease, extending from the
time of exposure to onset of disease symptoms, is usually
called the incubation period for infectious diseases, and the
latency period for chronic diseases. During this stage,
disease is said to be asymptomatic (no symptoms) or
unapparent. This period may be as brief as seconds for
hypersensitivity and toxic reactions to as long as decades
for certain chronic diseases.
• For example, the typical incubation period for hepatitis A is
as long as 7 weeks. The latency period for leukemia to
become evident among survivors of the atomic bomb blast
in Hiroshima ranged from 2 to 12 years.
• Although disease is not apparent during the
incubation period, some pathologic changes may
be detectable with laboratory, radiographic, or
other screening methods.

• Most screening programs attempt to identify the

disease process during this stage, since
intervention at this early stage is likely to be more
effective than treatment given after the disease
has progressed and become symptomatic.
3. Stage of clinical disease:
The onset of symptoms marks the transition from
subclinical to clinical disease. Most diagnoses are
made during the stage of clinical disease.
4.Stage of disability or death (or recovery):

Ultimately, the disease process ends in either

recovery, disability or death.
 Stages Stage (1) Stage (2) Stage (3) Stage (4)
Susceptibility Pre-symptomatic Clinical disease Disability
disease

Description Risk factors Pathologic changes The person has Some diseases run
which assist the (damages) have developed signs and their course and
development of started to occur in the symptoms of the then resolve
disease exist, body to lead toward disease. The clinical completely either
but disease has illness, but di sease is stage of different spontaneously or
not developed not yet clinically diseases differs in by treat ment. In
detectable (no duration, severity and others, the di sease
manifestations of the outcome. The may result in a
disease). outcomes of this residual defect,
The disease can only stage may be leaving the person
be detected through recovery, disability disabled for a
special tests. or death. short or longer
This stage may lead duration. Still,
to the cli nical stage, other diseases will
or may sometimes end in death.
end in recovery Disability is
without development limitation of a
of any signs or person's activities
symptoms. including hi s role.

Examples Smoking Alveoli deteriorate Emphysema detected Persistent

by pulmonary difficulty of
function test breathing

 unvaccinated  Detection of  Common cold has

a short and mild  Polio patients
child is antibodies against
clinical stage. who developed
susceptible HIV in an
 Polio has a severe paralysis
to measles apparently healthy
clinical stage and become
person.
many patients disabled for t he
 Ova of intestinal rest of their
parasite in the stool develop paralysis.
 Rabies has a lives.
of apparently
relatively short but  Trachoma may
healthy children
severe clinical ends with
st age. blindness.
 Diabetes Mellitus  Rabies almost
has a relatively all results in
longer clinical death.
st age.
The spectrum of disease:

• In some people, however, the disease process may never

progress to clinically apparent illness. In others, the disease
process may result in illness that ranges from mild to
severe or fatal. This range is called the spectrum of disease.
• Spectrum of disease means: "a disease may present with
varying outcome (signs and symptoms) and severity".
• The spectrum of disease is primarily a population concept
while the natural history is primarily a concept related to
individuals.
• Because the spectrum of disease, which includes
asymptomatic and mild cases, the cases of illness
diagnosed by clinicians in the community often represent
only the tip of the iceberg. Many additional cases may be
too early to diagnose or may never progress to the
clinical stage.
• Unfortunately, persons with unapparent or undiagnosed
infections may be able to transmit infection to others.
Such persons who are infectious but have subclinical
disease are called carriers.
• Examples: Persons with measles, hepatitis A, and
several other diseases become infectious a few days
before the onset of symptoms. However, carriers may
also be persons who appear to have recovered from
their clinical illness but remain infectious, such as
chronic carriers of hepatitis B virus, or persons who
never exhibited symptoms.
• The challenge to public health workers is that these
carriers, unaware that they are infected and infectious
to others, are sometimes more likely to unwittingly
spread infection than are people with obvious illness.
Susceptibility is a property of the host, and infectiousness is a
property of the agent
The following indicators can be calculated to delineate the spectrum
of a disease:

• Infectivity: "the proportion of exposed persons who become

infected".
Infectivity = Number of subjects infected X 100 %
Number of subjects exposed

• Pathogenicity: "the proportion of infected persons who

develop clinical disease".
Pathogenicity = Number of subjects manifesting the disease X 100 %
Number of subjects infected
• Virulence: "the proportion of persons with clinical disease who
become severely ill or die".
Virulence = Number of subjects with serious diseases (including mortality) X 100 %
Number of subjects with disease
 Examples
Hepatitis A virus in children has low
Pathogenicity and low virulence
In persons with good nutrition and health,
measles virus has high Pathogenicity but low characteristic rash illness but few develop the
virulence
Rabies virus is both highly pathogenic and
virulent
Explanations
Many infected children remain asymptomatic
and few develop severe illness
Almost all infected persons develop the
life-threatening presentations of measles,
pneumonia, or encephalitis
Virtually 100% of all infected persons (who
do not receive treatment) progress to clinical
disease and death
Disease causation
Cause of disease: is "an event, condition, characteristic or a combination of
these factors, which plays an important role in producing the disease".
The causes of disease can be classified into two:
1. Primary causes: factors that are necessary for a disease to occur, in whose
absence the disease will not occur. The term "etiologic agent" can be used
instead of primary cause for Infectious causes of diseases. For example,
“Mycobacterium tuberculosis” is the primary cause (etiologic agent) of
pulmonary tuberculosis.
2. Risk factors: factors that are not the necessary causes of disease but they
are important for a disease to occur. Risk factors could be related to the
agent, the host and the environment.
so, the etiology of a disease is the sum total of all the factors (primary causes
and risk factors) which contribute to the occurrence of the disease.
Models of disease causation:

1. Supernatural theory of disease:

• In the early past, the disease was thought either mainly due to the curse of god
or due to the evil force of the demons. Accordingly, people used to please the gods
by prayers and offerings or used to resort to witchcraft to tame the devils.
2. Ecological theory:
• Hippocrates is the first epidemiologist who advised to search the environment for
the cause of the disease.
• Environmental influence: interactions among humans, other living creatures,
plants, animals, microorganisms, ecosystems, geography and climate.
3. Germ theory:
• Microbes (germs) were found to be the cause for many known diseases.
Pasteur, Henle and Koch were the strong proponents of microbial theory after
they discovered the microorganisms in the patients’ secretions or excretions.
Henle-Koch postulates; sometimes called “pure determinism”
1. The agent is present in every case of the disease
2. Without that agent, that disease will not be caused (one agent - one disease).
3. It can be isolated.
4. If exposed to healthy subjects will cause the related disease

Causative agent Host Disease

4. Epidemiologic Triad:
According to this theory, not only the causative agent is responsible of causing
the disease but also there are other factors related to the host and
environment.
AGENT
• Agent of infection
• Host Agent Host
• Environment
Environment

Disease

HOST
ENVIRONMENT
5.Epidemiologic Tetrad:
Time is very important factor in disease
causation.
• Agent of infection
• Host
• Environment
• Time
6. BEINGS (or BBEINGSSS) theory:
This theory postulates that human disease and its
consequences are caused by a complex interplay of (9)
different factors:
• Biological factors
• Behavioral Factors
• Environmental factors
• Immunologic factors
• Nutritional factors
• Genetic factors
• Services and Social factors,
• and Spiritual factors
7. Multi-factorial causation theory:
This theory helps to address various associated causative
factors of a disease.

8. Epidemiological web causation:

McMahon and Pugh used this model to illustrate various
factors contributing to a disease wherein these factors are
linked like an interacting web of spider.

 Each factor has its own relative importance in causing the

final deviation from the state of health, as well as interact
with each other and modifying the effect of each other.
Web of Causation for the Major Cardiovascular Diseases
Web of Causation for pulmonary tuberculosis
9. Wheel causation:
• This theory has been postulated to explain the difference
between agent (intrinsic) factors and environmental (extrinsic)
factors in causing a disease.
• The theory visualize a human disease as a wheel, which has a
central hub representing the genetic components and peripheral
portions representing environmental components.
Types of Causal Relationships:

1. Necessary and 2. Necessary but not 3. Sufficient but not 4. Neither sufficient
sufficient sufficient necessary nor necessary
• Without the factor, • The factor should • The factor alone • The factor cannot
disease never be present in, but of can cause disease, cause disease on its
develops itself is not enough but so can other own, nor is it the
• With the factor, to cause disease factors in its absence only factor that can
disease always • Multiple factors are • Benzene or cause that disease
develops (this required, usually in a radiation can cause • This is the probable
situation rarely specific temporal leukemia without the model for chronic
occurs) sequence (such as presence of the disease relationships
carcinogenesis) other
Factors in Causation

Four types of factor play a part in causation of disease. All may be necessary
but will rarely be sufficient to cause a particular disease.
1. Predisposing factors– create a state of susceptibility, so the host become
vulnerable to a disease agent or necessary cause. e.g. age, sex or previous
illness.
2. Enabling factors – conditions that favor the development of disease. e.g.
low income, poor nutrition, bad housing or inadequate medical care.
• Conversely, circumstances that assist in recovery or in health maintenance
may be enabling factors.
3. Precipitating factors – those associated with
immediate exposure to a disease or noxious agent or
onset of disease. e.g. drinking contaminated water,
inhaling pollens in asthmatic attack or close contact
with a TB patient.
4. Reinforcing factors – factors that aggravate an
already established disease or state. e.g. repeated
exposure, malnutrition, undue work or stress.