Epi - Disease Causation

PRINCIPLES OF DISEASE
CAUSATION
Principles of Disease Causation
• Cause of a disease is an event, condition, or

characteristic that preceded the disease event and
without which the disease event either would not
have occurred at all, or would not have occurred
until some later time.
• Two principles of disease causation:

1. The single germ theory and
2. The ecological approach
1. The Germ theory
(Koch’s postulate)
• Robert Koch (1877) postulated a set rules for the

determination of causation.
Koch's Postulate states that:

1. The organism must be present in every case.
2. The organism must be isolated and grown in culture.
3. The organism must, when inoculated into a susceptible
animal, cause the specific disease.
4. The organism must again be isolated from the animal.
2. The Ecological approach
• Disease cannot be attributed to the operation of

any one factor
• The requirement that more than one factor be

present for disease to develop is referred to as
multiple causation or multifactorial etiology
• It is the interaction of the multiple factors which

determines whether or not a disease develops, and
this can be illustrated using different models.
A. Epidemiologic triangle
• The host, agent, and environment can coexist

harmoniously.
• Disease and injury occur only when there is
interaction or altered equilibrium between them.
• An agent, in combination with environmental
factors, can act on susceptible host to cause
disease
• Disruption of any link among these three factors
can also prevent disease.
Epidemiologic triangle…..
Epidemiologic triangle…..
I. The Agent
• Nutritive elements:
– Excessive (e.g. Cholesterol)
– Deficiency (e.g. Vitamins, Proteins)
• Chemical Agents: Carbon monoxide (CO)
• Physical Agents: Radiation
• Infectious Agents: bacteria, fungus, virus
7
Epidemiologic triangle….
II. Host Factors
Influence exposure, susceptibility or response to

agents
• Genetic: Age, Sex, genetic makeup
• Physiologic state: Pregnancy, Puberty, stress
• Immunologic condition: Active or passive immunity
• Human behavior: Hygiene, Diet handling
8
Epidemiologic triangle…
III. Environmental Factors
They influence existence of the agent, exposure, or

susceptibility to agent.
• Biological env’t: Infectious agents, vectors,
Reservoirs
• Social env’t: Socioeconomic, politics, norms
• Physical env’t: Seasonal changes, Heat, Industrial
wastes, air pollution
9
Example – Typhoid Fever
Salmonella Disease
Typhi
Young Age,
Low
Polluted
immunity,
water, open
Lack of
defecation
personal
hygiene
10
Example – Cervical cancer
Human Disease
Papilloma Virus
Old age,
Poverty, Lack multiple sex
of health partner, lack
facility of hygiene,
Smoking
11
B. Component Causes Model
• In this traditional model, each component cause is

seen as necessary and sufficient cause in itself to
produce the effect.
• Necessary cause: A causal factor whose presence is

required for the occurrence of the disease.
• Sufficient cause: A causal factor or collection of

factors whose presence is always followed by the
occurrence of the disease.
Example: Model for multiple causes
C. The web of causation
 Processes resulting disease

are much more complex.
 Developed especially to
enhance understanding of
chronic disease
 It emphasizes more on the
roles of other contributing
factors than the agent
Natural History of Disease
and
Levels of Prevention
15
Natural History of Disease
• The “natural history of disease” refers to the
progression of disease in an individual over time, in
the absence of intervention.
There are four stages in natural history of a disease:
16
Natural history…
i. Stage of susceptibility
• at this stage, disease has not yet developed, but the
groundwork has been laid by the presence of factors
that favor its occurrence.
e.g. unvaccinated child is susceptible to measles.
unprotected sex makes susceptible to HIV
high cholesterol increases risk of CHD
17
Natural history…
ii. Stage of Pre-symptomatic (sub-clinical) disease

• no manifestations of the disease but pathologic
changes have started to occur in the body.
• At this stage disease can only be detected by lab tests
since signs and symptoms are not present.
e.g. HIV in an apparently healthy person.
This stage may lead to the clinical stage, or may

sometimes end in recovery
18
Natural history…
iii. Clinical stage
• Apparent signs and symptoms of the disease.
• Differs in duration, severity and outcome.
• outcomes of the stage may be recovery, disability or
death.
e.g. - Common cold: short, mild, quick recovery
- Polio: severe, paralysis, permanent disability
- Rabies: short, severe, death
19
Natural history…
iv. Stage of recovery, disability or death
• Some diseases run their course and then resolve
spontaneously;
• Others may result in defect or disability, short/lifelong;
• Still, other diseases will end in death
e.g. – Trachoma blindness

- Meningitis blindness or deafness, and
sometimes may also result in death
20
The Spectrum of Illness from
infectious Disease
Inapparent Mild Severe Death

infection Disease Disease
No signs or Clinical illness with signs and

symptoms symptoms
Natural History Patterns of
Selected Infectious Diseases
Natural History Disease

Acute with recovery and long-
Measles, mumps, rubella, polio
term immunity
Acute with some chronic HBV, HSV-1 and -2, Chlamydia

carriers trachomatis infections
Acute, chronic sequelae Group A streptococcal, syphilis,

without carrier state lyme disease
HIV, HBV, HPV, Helicobacter pylori

Chronic with carriers common
infections, Schistosoma infections
Outcomes at Each Stage of Infection
Exposure Infection Disease Disease Outcome
Infectiousness Pathogenesis Virulence

(Infection rate) (Clinical to sub-clinical ratio) (Case-fatality rate,
Hospitalization rate)
Infectivity: infectious agent’s ability to cause infection in a susceptible host

Pathogenicity: ability of infectious agent to produce clinical disease.
Virulence: ability of infectious agent to result in a severe clinical disease.
Ranking of Infection by Infectivity,
Pathogenicity, and Virulence
Severity Infectivity Pathogenicity Virulence
Smallpox Rabies
Smallpox
Rabies
Smallpox
High Measles Measles
Chicken pox Tuberculosis
Chicken pox Common cold Leprosy
Rubella
Rubella Poliomyelitis
Intermediate Mumps
Mumps Measles
Common cold
Poliomyelitis Measles
Low Tuberculosis
Tuberculosis Chicken pox
Rubella
Very low Leprosy Leprosy
Common cold
Time Course of a Disease in Relation to Its
Clinical Expression and Communicability
Incubation period Symptomatic period

Latent Infectious period Latent
Time lines for Infection and Disease
Time of Infection
Dynamics of Noninfectious
Infectiousness Latent period Infectious
period -removed
-dead
Susceptible -recovered
Dynamics of
Disease
Incubation Symptomatic Non-diseased
period period -removed
-dead
-recovered
Susceptible
Time course of an infectious disease
Latent: interval from exposure to infectiousness; or, from

recovery to relapse in clinical disease
Incubation period: interval from exposure to an agent to

the onset of symptoms
Infectious period: time during which agent is shed
Generation period: b/n exposure/infection and maximum

communicability of the infectious agent
Convalescent period: from recovery until shedding of

infectious agent stops
27
Application of time periods
Pre-patent period - When should we investigate?
Incubation period - When was the time of exposure?
Communicable period - When should we take care of

infectiousness to others?
Latent period - When would relapse occur?
Convalescent period – for how long an individual stays

infectious after recovery?
Generation time - When is the maximum risk for contacts?

28
Incubation Periods of Selected
Exposures
Exposure Usual Incubation Period

HIV < 1 to 15+ years
Salmonella 6–48 hours
Varicella-zoster virus 14 – 16 days
Treponema pallidum about 3 weeks
Hepatitis B virus 2 – 3 months
Levels of Disease Prevention
Three major levels of disease prevention
1. Primary prevention
• Involves eliminating causes of disease or
increasing resistance to disease
Targeted at healthy people
• Main objectives are promotion of health, prevention
of exposure, and prevention of disease
30
Levels of prevention…
A. Health promotion
– Improvement of socioeconomic status,
provision of adequate food, housing, clothing,
and education.
B. Prevention of exposure
– Provision of safe and adequate water, proper
excreta disposal, and vector control.
C. Prevention of disease
– Immunization
31
2. Secondary prevention
• Involves early detection & treatment
• Objective is to stop or slow progression of
disease to prevent or limit permanent damage
Targeted at sick individuals
– Prevention of blindness from Trachoma

– Early detection and treatment of breast cancer to
prevent its progression and improve survival
32
3. Tertiary prevention
• Involves rehabilitation services
• Objective is to prevent further disability or death
and limit physical, social, psychological and
financial impacts of disability
Targeted at people with chronic diseases and

permanent disabilities
– Rehabilitation for fistula, leprosy
33
Levels of prevention & Natural History of Disease
Levels of Disease Prevention
Level
Stage of disease Target
of Prevention
Existence of
Total population and
Primordial underlying condition
selected groups
leading to causation
Total population,
Specific causal
Primary selected groups and
factors exist
health individuals
Secondary Early stage of disease Patients
Late stage of disease

Tertiary (treatment & Patients
rehabilitation)
Advantages and Disadvantages
of strategies for primary prevention
Population-based High-risk group

• Radical • Appropriate to individual
• Identification of high-risk • Subject motivation high
groups not necessary
Advantages • Health professionals
motivation high
• Favorable benefit-to-risk ratio
• Small benefits to individuals • Identifying high risk group is

difficult
• Poor motivation of subjects
• Temporary effect
Disadvantages • Poor motivation of Health
professionals • Limited effect

Epi - Disease Causation

Uploaded by

Copyright:

Available Formats

Epi - Disease Causation

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Epi - Disease Causation

Uploaded by

Copyright:

Available Formats

PRINCIPLES OF DISEASE

• Cause of a disease is an event, condition, or

• Two principles of disease causation:

• Robert Koch (1877) postulated a set rules for the

Koch's Postulate states that:

• Disease cannot be attributed to the operation of

• The requirement that more than one factor be

• It is the interaction of the multiple factors which

• The host, agent, and environment can coexist

II. Host Factors

Influence exposure, susceptibility or response to

III. Environmental Factors

They influence existence of the agent, exposure, or

• In this traditional model, each component cause is

• Necessary cause: A causal factor whose presence is

• Sufficient cause: A causal factor or collection of

 Processes resulting disease

ii. Stage of Pre-symptomatic (sub-clinical) disease

This stage may lead to the clinical stage, or may

e.g. – Trachoma blindness

Inapparent Mild Severe Death

No signs or Clinical illness with signs and

Natural History Disease

Acute with some chronic HBV, HSV-1 and -2, Chlamydia

Acute, chronic sequelae Group A streptococcal, syphilis,

HIV, HBV, HPV, Helicobacter pylori

Exposure Infection Disease Disease Outcome

Infectiousness Pathogenesis Virulence

Infectivity: infectious agent’s ability to cause infection in a susceptible host

Incubation period Symptomatic period

Latent: interval from exposure to infectiousness; or, from

Incubation period: interval from exposure to an agent to

Infectious period: time during which agent is shed

Generation period: b/n exposure/infection and maximum

Convalescent period: from recovery until shedding of

Pre-patent period - When should we investigate?

Incubation period - When was the time of exposure?

Communicable period - When should we take care of

Latent period - When would relapse occur?

Convalescent period – for how long an individual stays

Generation time - When is the maximum risk for contacts?

Exposure Usual Incubation Period

Three major levels of disease prevention

Targeted at sick individuals

– Prevention of blindness from Trachoma

Targeted at people with chronic diseases and

– Rehabilitation for fistula, leprosy

Secondary Early stage of disease Patients

Late stage of disease

Population-based High-risk group

• Small benefits to individuals • Identifying high risk group is

You might also like