Concept of cause

Alick Mwambungu
Mwambungup@yahoo.com

Session 11

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 Cause
• An understanding of the cause of disease
is important in the health field not only for
prevention but also in diagnosis and the
application of correct treatment.
• A cause of a disease is an
event,condition,characteristic or a
combination of these factors which plays
an important role in producing the
disease.
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 Causality
• We are interested in finding the causes of
diseases because we want to be able to
intervene to prevent disease from
occurring.
• The ideas about why, where and how are
influenced by concepts of diseases and
the wider frame of reference in which we
operate.

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 Causality
• Logically a cause must precede a disease.
• A cause is termed sufficient when it
inevitably produces or initiates a disease
• termed necessary if a disease can not
develop in its absence.
• A sufficient cause is not usually a single
factor, but often comprises several
components.
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 Types of Causes
Causes that act together are
classified as necessary and
sufficient.

• Necessary
cause–a factor
found in all cases

• Sufficient cause–
a combination of
factors that makes
disease inevitable
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• Example: Cigarette smoking is one component
of the sufficient cause of lung cancer.
• Smoking is not sufficient in itself to produce the
disease.
• Some people smoke for 50 yrs without
developing lung cancer; other factors mostly
unknown are required.
• However, the cessation of smoking reduces the
number of cases of lung cancer in a population
even if the other component are not altered.

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• Each sufficient cause has a necessary cause as
a component eg.In a study of an outbreak of
food borne infection, it may be found that
chicken salad and creamy dessert were both
sufficient causes of salmonella diarrhoea.
• The occurrence of salmonella is the necessary
cause of this disease.
• Similarly, there are different components in the
causation of tuberculosis, but the tubercle
bacillus is a necessary cause.

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• A single component cause is rarely a
sufficient cause by itself.
• For example, even exposure to a highly
infectious agent such as measles virus
does not invariably result in measles
disease-the host must be susceptible;
other host factors may also play a role.

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• An agent which rarely causes disease in healthy
persons may be pathogenic when other
conditions are right.
• Pneumocystits carinii is one such organism,
harmlessly colonizing some healthy persons but
causing potentially lethal pneumonia in persons
whose immune systems have been weakened
by HIV.
• Presence of Pneumocystitis carinii organisms is
therefore a necessary but not sufficient cause of
pneumocystis pneumonia.
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 Factors in causation
• Three types of factor play a part in causation of
disease. All may be necessary but they are
rarely sufficient to cause a particular disease or
state.
• Predisposing factor :sex,age,previous illness
• Enabling factors: Low income, poor nutrition,
bad housing, inadequate medical care.
• Precipitating factors: Exposure to a specific
agent or noxious agent.

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 Establishing the cause of diseases
• Causal inference:
This is the term used for the process of
determining whether observed
associations are likely to be causal.

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 Interaction
• The effect of two or more causes acting
together is often greater than would be
expected on the basis of summing the
individual effects:
Lung cancer=Smoking + Asbestos exposure.

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 Sanitary movement
• Cause: a combination of unfavourable living
conditions thought to lead to the general burden
of disease.
• Where: factors operating at community level
were the causes of disease.
• How: Documented mortality rates in different
communities and found many associations
between mortality rates and these population
based variables.
• They took these associations to be proof of
causation.

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 Germ theory
• Cause: A single specific agent that inevitably
produced specific disease outcome-physical
entity, that could be isolated in lab
• Where: Efforts at disease prevention were
concentrated at the individual level.
• How:- the agent must be found in every case
-the agent must not be found in other disease.
-should be able to reproduce disease in
experimental animals.
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• Pasteur's work on microorganisms led to
the formulation of the following rules by
Koch for determining whether a specific
living organism causes a particular
disease.

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 Koch’s Postulates

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 Multi-causality
• Cause: any factor that plays an essential role in
producing an occurrence of diseases i.e. a
number of factors act together.
• Where: there are no upper or lower limits to the
level at which we could search for causes.
• How: find association between exposure and
outcome.
• Decide whether the association is valid
considering alternative explanations.

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 Multi-causality
• We do not make judgement about
causality on the basis of one association
• We need to take into account other
evidence from a number of different
sources and the coherence of the
association with existing theory and
knowledge.

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 Hills Criteria of Causation
• Outlines the minimal conditions needed to
establish a causal relationship between two
items.
• These criteria were originally presented by
Austin Bradford Hill (1897-1991).
• A British medical statistician
• As a way of determining the causal link
between a specific factor (e.g. cigarette
smoking) and a disease (such as emphysema
or lung cancer).

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• Hill's Criteria form the basis of modern
epidemiological research, which
attempts to establish scientifically valid
causal connections between potential
disease agents and the many diseases
that afflict humankind.

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 Sir Austin Bradford Hill(1897-1991)

-Temporality
-Strength
-Consistency
-Dose-response relationship
– Specificity
– Biological plausibility
– Coherence
– Reversibility (Experimental)
– Analogy
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 1.Temporality or Time Sequence
• For judgement of causality to be
reasonable, the exposure of interest
should precede the outcome by a period
of time consistent with biologic mechanism

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 Bradford Hill Criteria
• Temporality
Exposure must precede outcome

Exposure Time Outcome

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 2.Strength
• The strength of an association is
measured by risk ratio, or odds ratio.
• The stronger the association the more
likely it is to be causal.

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 3.Consistency
• Cause-effect relationship can be supported if the
outcome is consistency.
• The outcome has been supported by a number
of studies conducted by different investigators
at various times using various epidemiological
study designs (cross-section, case-control or
cohort studies) among different populations and
cultural setting.
• Have similar results been shown in other
studies?

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 4.Biological gradient
• Risk of an outcome increases with an
increase in the dose of exposure (dose-
response relationship). e.g. the more
cigarettes smoked per day, the higher the
risk of developing lung cancer.

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 5.Specificity
• This is established when a single putative cause
produces a specific effect.
• This is considered by some to be the weakest of
all the criteria.
• The diseases attributed to cigarette smoking, for
example, do not meet this criteria.
• When specificity of an association is found, it
provides additional support for a causal
relationship.
• However, absence of specificity in no way
negates a causal relationship.

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 6.Biological Plausibility
• Postulated biologic mechanism by which the exposure
might reasonably alter the risk of developing the disease.

• For example the belief that the daily consumption of

small to moderate amounts of alcohol reduces the risk of
developing CHD.

• This is enhanced by the fact that there is a plausible

biologic mechanism that alcohol raises high-density
lipoprotein (HDL) Cholesterol.
• Increased levels of which decrease risk of CHD.

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 7.Coherence
• A causal relationship is more likely if it
does not conflict with current knowledge
about natural history and biology of
disease.

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 8.Experimental(Reversibility)
• Causality is supported if removal of the
exposure leads to a reduction in the risk of
the outcome.
• Provides very strong evidence in favour of
causal relationship.

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 9.Analogy
• If we already know that a particular
exposure causes a specific outcome, then
we are more likely to accept that a similar
exposure is the cause for a similar
outcome.
• when one class of causal agents is known
to have produced an effect, it can easily
be accepted that another agent of that
class produces a similar effect.

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• Human papilloma virus causes Cervical
cancer.
• Other DNA tumour viruses can induce
cancers in humans, and species-specific
papillomaviruses can induce cancers in
animals.

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