Spectrum & Natural History Of Disease.

Iceberg Phenomenon. Levels Of Prevention.

Disease Surveillance. Disease Elimination &
Eradication.

Dr. Tauseef Ismail

Assistant Professor,
Department of Community Medicine,
KGMC
 Objectives
After attending this lecture, students will be able
to:
1. Describe spectrum of disease
2. Explain natural history of disease
3. Discuss theories of disease causation
4. Differentiate between disease Elimination &
Eradication.

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 Spectrum of Disease
• At one end are subclinical infections which are
not ordinarily identified and at the other end are
fatal illnesses.
• In the middle of the spectrum lie illnesses ranging
in severity from mild to severe.
• In infectious diseases, the spectrum of disease is
also referred to as the “gradient of infection”.

Cont’d

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• Leprosy is an excellent example of the spectral
concept of disease.
• Rabies: For almost every disease there exists a
spectrum of severity, with few exceptions such as
Rabies
• HIV (in apparent, to mild e.g. AIDS-related
complex to severe e.g., wasting syndrome)
• Coronary Artery Disease: asymptomatic form
(atherosclerosis), transient myocardial ischemia,
& myocardial infarctions of various severities.

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The sequence of events in the spectrum of
disease can be interrupted by early diagnosis
and treatment or by preventive measures which
if introduced at a particular point will prevent or
retard the further development of the disease.

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 Natural History of Disease

• The process by which diseases occur

and progress in humans in the absence
of intervention.

• The process begins with exposure to or

accumulation of factors capable of
causing disease.

• Without medical intervention, the

process ends with recovery, disability, or
death.

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 Natural History of Disease
Exposure to Agent
Symptom
Development
Pre-exposure
Stage: Preclinical
Stage:
Factors
present Exposure to Clinical Resolution
leading to causative Stage: Stage:
problem agent: no
development symptoms Symptoms Problem resolved.
present present Returned to health
or chronic state or
death

Primary Secondary
Tertiary
Prevention Prevention
Prevention

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Typical course of infectious disease
TIME

Susceptible Subclinical Death

Disease
Host
Clinical
Disease
No
infection
Recovery

Incubation
period
Exposure Onset

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 Theories of Disease Causation

1. Supernatural theory of disease

2. Ecological theory
3. Germ theory
4. Epidemiological Triad
5. Multifactorial causation theory or web of causation.

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 SUPERNATURAL THEORY OF DISEASE

In the early past, the disease was thought

mainly due to either 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.

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 NO UNANIMOUS OPINION
• At least 10% of the people in developed countries
and 30% in developing countries still believe in
supernatural origin
• Even today superstitions are becoming major
obstacles in disease control
• Most of the literates view that disease is the result of
microbes
• Most of the uneducated people (90%) believe that
disease is due to bad physical environment

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 ECOLOGICAL THEORY

• Around 463 BC, HIPPOCRATES was the

first epidemiologist who advised to
search the environment for the cause of
the disease.

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 Environmental Influence

• Interactions among humans, other living

creatures, plants, animals, micro
organisms, ecosystems and climate,
geography, and topography are so
complex that despite much study we are
often uncertain what is really happening.

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 ECOLOGICAL DETERMINANTS OF
DISEASE
• Thomas McKeown emphasized the importance of
economic growth, rising living standards, and
improved nutrition as the primary sources of
most historical improvements in the health of
developed nations.
• He pointed out that improved health owes less to
advances in medical science than to the
operation of natural ecological laws

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 GERM THEORY

• Germ theory: Microbes

(germs) were found to be the
cause for many known
diseases. Pasteur, Henle, Koch
were the strong proponents of
microbial theory after they
discovered the micro-
organisms in the patients’
secretions or excretions.

ROBERT KOCH
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 Robert Koch’s Postulates
• The microorganism must be found in abundance in all organisms
suffering from the disease, but should not be found in healthy
organisms.
• The microorganism must be isolated from a diseased organism and
grown in pure culture.
• The cultured microorganism should cause disease when introduced
into a healthy organism.
• The microorganism must be re-isolated from the inoculated, diseased
experimental host and identified as being identical to the original
specific causative agent.

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 Epidemiologic Triad

Disease is the result

of forces within a
dynamic system
consisting of:

agent of infection
host
environment

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 Classic Epidemiologic Theory
• Agents
– Living organisms
– Exogenous chemicals
– Genetic traits
– Psychological factors and stress
– Nutritive elements
– Endogenous chemicals
– Physical forces
• Agents have characteristics such as infectivity,
pathogenicity and virulence (ability to cause
serious disease)
– They may be transmitted to hosts via vectors

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 Classic Epidemiologic Theory (cont.)
• Host factors:
– Immunity and immunologic response
– Host behavior

• Environmental factors:
– Physical environment (heat, cold, moisture)
– Biologic environment (flora, fauna)
– Social environment (economic, political, culture)

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Multifactorial Causation Theory Or
Web Of Causation

Pettenkofer stated that

agent, host and
environmental factors will
act & interact synergistically
and act as joint
independent partners in
causing the disease.
Pettenkofer
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Web of Causation for the Major Cardiovascular Diseases

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 Causal Relationships
• A causal pathway may be direct or indirect

• In direct causation, A causes B without intermediate

effects

• In indirect causation, A causes B, but with intermediate

effects

• In human biology, intermediate steps are virtually always

present in any causal process

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 Types of Causal Relationships
• Necessary and sufficient – without the factor, disease never develops
– With the factor, disease always develops (this situation rarely occurs)

• Necessary but not sufficient – the factor in and of itself is not enough to cause
disease
– Multiple factors are required, usually in a specific temporal sequence (such
as carcinogenesis)

• Sufficient but not necessary – the factor alone can cause disease, but so can
other factors in its absence
– Benzene or radiation can cause leukemia without the presence of the other

• Neither sufficient nor necessary – the factor cannot cause disease on its own,
nor is it the only factor that can cause that disease
– This is the probable model for chronic disease relationships

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 Assignment
Differentiate between disease Elimination and
Eradication with real life examples.

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 References
• Afzal S, Jalal S. Textbook of Community
Medicine and Public Health. Pakistan:
paramount Books (Pvt.) Ltd. 2018. Chapter 3:
Health Policy; p.89-98

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 “Iceberg” concept of infectious disease in
populations

DEATH
CLINICAL
DISEASE SEVERE
DISEASE

SUB CLINICAL MILD ILLNESS

DISEASE

INFECTION WITHOUT
CLINICAL ILLNESS

EXPOSURE WITHOUT INFECTION

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 Iceberg Concept of Infection
CELL RESPONSE HOST RESPONSE
Lysis of cell Fatal
Discernable Clinical and Clinical
effect Cell transformation severe disease Disease
or
Cell dysfunction Moderate severity
Mild Illness

Incomplete viral Infection without

Below visual maturation clinical illness Subclinical
change Disease
Exposure Exposure
without cell entry without infection

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Subclinical/Clinical Ratio for Viral Infections

Virus Clinical feature Age at infection Estimated ratio Clinical cases

Polio Paralysis Child + 1000:1 0.1% to 1.0%

Epstein-Barr Mononucleosis 1 to 5 years > 100:1 1%
6 to 15 years 10:1 to 100:1 1% to 10%
16 to 25 years 2:1 to 3:1 50% to 75%
Hepatitis A Icterus < 5 years 20:1 5%
5 to 9 years 11:1 10%
10 to 15 years 7:1 14%
Adult 1.5:1 80% to 95%
Rubella Rash 5 to 20 years 2:1 50%
Influenza Fever, cough Young adult 1.5:1 60%
Measles Rash, fever 5 to 20 years 1:99 >99%
Rabies CNS symptoms Any age <1:10,000 >>>>99%
 Levels of Prevention
• Primordial Prevention
• Primary Level of Prevention
• Secondary Level of Prevention
• Tertiary Level of Prevention

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 Primordial Prevention
• Primordial prevention is defined as prevention of risk
factors themselves, beginning with change in social
and environmental conditions in which these factors
are observed to develop, and continuing for high risk
children, adolescents and young adults.
• A relatively new concept, is receiving special
attention in the prevention of chronic diseases. For
example, many adult health problems (e.g. obesity,
hypertension) have their early origins in childhood,
because this is the time when lifestyles are formed.
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 Primary Level of Prevention
• Control the underlying cause or condition that
may result in disability.
• e.g. maternal antiretroviral therapy to reduce the
risk of mother-to-child transmission of HIV;
fortification of the food supply to prevent birth
defects such as spina bifida and iodine deficiency
disorders.
• Immunization against infectious diseases
• Edu. & legislation about proper seatbelt & helmet
use. Cont’d

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 Primary Prevention
• Education about good nutrition, the
importance of regular exercise, & the dangers
of tobacco, alcohol and other drugs.
• Regular exams and screening tests to monitor
risk factors for illness
• Controlling potential hazards at home and in
the workplace.

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 Secondary Level of Prevention
• Aims at preventing an existing illness or injury
from progressing to long-term disability
• e.g. telling people to take daily, low-dose
aspirin to prevent a 2nd heart attack or stroke.
• Providing suitably modified work for injured
workers; effective emergency medical care for
head injury

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 Tertiary Level of Prevention
• Rehabilitation and special educational services
to mitigate disability and improve functional
and participatory or social outcomes once
disability has occurred.
• e.g. rehabilitation of post-stroke patients.
• Chronic pain management programs.
• Patient support groups.

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PRIMARY SECONDARY TERTIARY

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Q-1) Which level of prevention is applicable for
implementation in a population without any risk factors?
a) Primordial Prevention
b) Primary Prevention
c) Secondary Prevention
d) Tertiary Prevention
Q-2) Morbidity in a community can best be estimated by:
a) Active surveillance
b) Sentinel surveillance
c) Passive surveillance
d) monitoring

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Q-3) The term ‘Disease Control’ employs all of the
following except:
a) Reducing the complications
b) Reducing the risk of further transmission
c) Reducing the incidence of disease
d) Reducing the prevalence of disease
Q-4) In the natural Hx of disease, the ‘Pathogenesis phase’
is deemed to start upon:
a) Entry of the disease agent in the human host
b) Interaction between agent, host and environmental
factors
c) Appearance of signs and symptoms
d) Appearance of complications
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THANKS

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