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DISEASE
Contents
Introduction
Models of disease causation
Factors of disease causation
Natural history of disease in man
Levels of prevention
Quantifying prognosis
Definition
Natural history of disease refers to the progress of a
host
disease
disability
death
studies,
such
as
cross-sectional
and
For the public health worker, the challenge is that persons with
undiagnosed infections may nevertheless be able to transmit
them to others.
DE
AT
H
SEVERE
DISEASE
MILD ILLNESS
INFECTION WITHOUT
CLINICAL ILLNESS
Models of disease
causation
Models of disease
causation
Germ theory of disease
Epidemiological Triad
Epidemiological Tetrad
BEINGS theory
Web of Causation theory
Wheel theory
ROBERT KOCH
LOUIS PASTEUR
Epidemiological Triad
Epidemiological Triad
Agent
Is an element or substance, animate or inanimate, the presence
(or absence) of which may initiate or perpetuate a disease
process.
A disease may have a single agent, a number of independent
alternative agents or complex of two or more factors whose
combined presence is essential for the development of the
disease.
Agent
Classification of agents:
Biological
Nutrient
Physical
Chemical
Mechanical
Absence or insufficiency or excess of a factor necessary to
health
Social
Agent characteristics
Infectivity refers to the proportion of exposed persons who
become infected.
Pathogenicity refers to the proportion of infected persons who
develop clinical disease.
Virulence refers to the proportion of persons with clinical
disease who become severely ill or die.
Agent characteristics
Hepatitis A virus in children has low pathogenicity and low virulence,
since many infected children remain asymptomatic and few develop
severe illness.
In persons with good nutrition and health, measles virus has high
pathogenicity but low virulence, since almost all infected persons
develop the characteristic rash and illness but few develop the lifethreatening presentations of measles (pneumonia, encephalitis).
Host
In epidemiological terminology, the human host is referred to
as soil and the disease agent as seed.
A person or other living animal, that affords subsistence or
lodgment to an infectious agent under natural condition.
Host factors: Intrinsic factors that influence an individuals
exposure, susceptibility, or response to a causative agent.
Environment
Physical environment
Non living things and physical factors(air, water, soil,
HOST
FACTORS
AGENT
1.Decreased
immunity
2.Malnutrition
3.Elderly
4.HIV infection
M. Tuberculosis
ENVIRONMENT
FACTORS
1.Poor housing
2.Overcrowding
3.Poverty
4.Urbanization
Epidemiological Tetrad
Agent
Host
Environment
Time
Disease Occurrence
Disease Occurrence
Epidemic: occurrence in a community or region of a group of
illnesses of similar nature, clearly in excess of normal
expectancy and derived from a common or from a propagated
source.
Public health officials often use the term outbreak, which
means the same, because it is less provocative to the public.
When an epidemic spreads over several countries or
continents, affecting a large number of people, it is called a
pandemic(worldwide epidemic).
Web of causation
McMahon and Pugh forwarded the theory of epidemiological
web of causation, wherein the various factors (e.g.
hypercholesterolemia, smoking, hypertension) are like an
interacting web of a spider.
Malnutrition
Exposure to
Mycobacterium
Susceptible Host
Infection
Tuberculosi
s
Tissue Invasion
and Reaction
Vaccination
Genetic
Epidemiologic Triad
devised to enhance search for
understanding communicable disease
Web of Causation
devised to address non-communicable
diseases can also be applied to
communicable disease
Wheel theory
As medical knowledge advanced, an additional aspect of
interest that came into play is the comparative role of
genetic and the environmental (i.e. extrinsic factors
outside the host) factors in causation of disease.
Wheel theory
The theory visualizes human disease in the form of a wheel, which
has a central hub representing the genetic components and the
peripheral portion representing the environmental component.
Wheel Theory
Wheel Theory
Factors of disease
causation
Exposure to
TB
No infection(70-90%)
Infection(10-30%)
Untreated
50% die within 5 years
25% remain sick
25% recover
Treated
Cured
(A)
(P)
Clinical Phase
(S)
(M)
(D)
(T)
Primordial prevention
Prevention of the emergence or development of risk factors.
Particularly useful for chronic diseases.
Example :Many adult health problems (e.g., obesity,
hypertension) have their early origins in childhood, because
this is the time when lifestyles are formed (smoking, eating
patterns, physical exercise).
Efforts are directed towards discouraging children from
adopting harmful lifestyles .
The main intervention is through individual and mass
education.
Primary prevention
Measures of prevention undertaken during the phase of prepathogenesis (phase of susceptibility)
Involves two sub-steps: Health promotion and specific protection
Health Promotion : Steps undertaken to improve the level of
general health and well being so that conditions for initiation of
disease process are prevented.
These steps are not specific for any disease or a group of diseases.
Primary prevention
It includes
improvement in the overall socio-economic status of the
population,
health education,
feeding programmes for mothers and children,
promotion of breast feeding,
promotion of small family norms,
education
motivation for healthy lifestyle.
Primary prevention
Specific Protection : include measures to prevent the initiation of
iodine)
Use of condoms to protect against sexually transmitted
diseases (STDs)
Use of helmets to protect against head injuries
Primary prevention
Both health promotion and specific protection are type of
primary preventive strategy.
However, health promotional approach improves the general
health so that a number of diseases are aimed at.
For example, by promoting breast feeding among children, we
try to prevent general malnutrition, vitamin A deficiency,
providing antibodies against various diseases, preventing
diarrhoeal diseases.
On the other hand when condom is used, it is for a very
specific group of diseases i.e. STDs; when measles vaccine is
given it is for a specific disease viz. measles.
Primary prevention
Two types of strategy:
Population strategy
High risk strategy
Primary prevention
Population strategy
Advantages:
Radical
Large potential for population
Behaviourally appropriate
Advantages :
Appropriate to individuals
Subject motivation
Physician motivation
Benefit to risk ratio is favourable
Disadvantages:
Small benefits to individual
Poor motivation of subject
Poor motivation of physician
Benefit to risk ratio may be low
Disadvantages:
High screening costs.
Temporary effects
Limited effect
Behaviourally inappropriate
Prevention Paradox
A preventive measure which brings much benefit to the
population often offers little to each participating individual.
Classical example is the Framingham study:
Data from the study suggests that if all men upto age 55
reduced their cholesterol level by 10%, 1 in 50 could
expect to avoid a heart attack on average, yet 49 out of 50
would follow the same measures and perhaps get nothing
out of it.
Secondary Prevention
These include all actions undertaken at the stage of early
pathogenesis (asymptomatic disease) with a view to halt the
progress of disease at its earliest, incipient stage, by early
diagnosis and prompt treatment.
classical example is screening for disease for breast cancer
(using mammography) and cervical cancer (using pap smear).
medical examinations of school children, of industrial workers
and various disease screening camps.
Tertiary prevention
These include all measures undertaken when the disease has become
clinically manifest or advanced, with a view to prevent or delay death,
reduce or limit the impairments and disabilities, minimize suffering and to
promote the subjects adjustment to irremediable conditions.
Tertiary prevention
Disability Limitation : These include all measures to prevent
the occurrence of further complications, impairments,
disabilities and handicaps or even death. example :
Application of plaster cast to a patient who has suffered
Colles fracture, is done to prevent complications and
further disability like mal-union or non-union.
Complete rest, morphine, oxygen and streptokinase is
given to a patient of Acute MI, to prevent death or
complications like arrhythmias / CHF.
Tertiary prevention
The sequence with which a disease turns into a handicap is as
follows :
Disease : This is a pathological process and its manifestations
which indicate a departure from the state of perfect health.
Impairment : This is the actual loss or damage of a part of
body anatomy or an aberration of the physiological functions
that occurs consequent to a disease.
Disability : This is defined as the inability to carry out certain
functions or activities which are otherwise expected for that
age / sex, as a result of the impairment.
Handicap : This is the final disadvantage in life which occurs
consequent to an impairment or disability, which limits the
fulfillment of the role a person is required to play in life.
Tertiary prevention
Rehabilitation : This is the second component of tertiary
prevention.
Tertiary prevention
Medical rehabilitation :
This is done through medical / surgical procedures to restore
the anatomy, anatomical functions and physiological functions
to as near normal as possible.
Vocational rehabilitation :
It includes steps involving training and education so as to
enable the person to earn a livelihood.
Social rehabilitation :
This involves steps for restoration of the family and social
relationships.
Emotional and Psychological rehabilitation :
This involves steps to restore the confidence, personal dignity
and confidence.
Levels of Prevention
Level of prevention
Phase of disease
Target
Primordial
Primary
Secondary
Patients
Tertiary
Patients
Death
CFR
Survival
5 year
survival
Observed
survival
Median
survival
Relative
survival
Lead Time
Lead time is the time between the early detection of disease
(e.g by screening) and the time of its usual clinical diagnosis.
Lead time bias occurs because of the failure to account for the
lead time when calculating survival.
References
Parks Textbook of preventive and social medicine, 21 st edition
Textbook of Epidemiology, Leon Gordis, 4 th edition.
Textbook of public health and community medicine, AFMC,2009
Measures of prognosis, Bloomberg School of Public Health,2008
CDC , Principles of Epidemiology in Public Health Practice, 3rd
Edition