CONTENTS

• INTRODUCTION
• CONCEPTS OF DISEASE
• CONCEPTS OF CAUSATION
• NATURAL HISTORY OF DISEASE
• CONCEPTS OF CONTROL
• CONCEPTS OF PREVENTION
• CHANGING PATTERN OF DISEASE
• DISEASE CLASSIFICATION
• CONCLUSION
2
 INTRODUCTION
• The concept of disease has been the subject of a vast,
vivid and versatile debate.

• Disease is a central notion to modern health care, it

effects society and is important to the process of
discovering and identifying disease entities.

3
CONCEPTS OF DISEASE
DEFINITIONS
“A condition in which body function is impaired, departure from a state
of health, an alteration of the human body interrupting the
performance of the vital functions.”

“The condition of body or some part of organ of body

in which its functions are disrupted or deranged.”

“Disease is considered a social phenomenon, occuring in all

societies and defined and fought in terms of the particular
cultural forces prevalent in the society.”

‘a maladjustment of human organism to the environment’

4
TO KEEP IT SIMPLE
Simplest definition – OPPOSITE TO HEALTH .

Any deviation from normal functioning or state of

complete physical or mental well-being.
5
DISEASE ILLNESS SICKNESS

ILLNESS SICKNESS
DISEASE is a physiological/
is a subjective state is a state of social
psychological dysfunction.
of the person who dysfunction i.e. a
feels aware of not role that the
being well. individual assumes
Susser when ill (sickness
role). 6
CONCEPT
EARLIER THEORIES
OF CAUSATION
• Supernatural theory

• Theory of Humors

• Concept of contagion
Discovery of microbiology - turningpoint
• Miasmatic theory
• GERM THEORY OF DISEASE
• Theory of spontaneous generation
• Microbes as sole cause of disease

7
EPIDEMIOLOGICAL TRIAD
• Factors relating host and environment

• Mission of epidemiology – break one of the legs of

triangle and disrupt the connection between these and
thereby stopping outbreak. 8
THE TETRAD OF EPIDEMIOLOGY

9
MULTIFACTORIAL CAUSATION
• CONCEPT- disease is due to multiple factors and not
a single one.
• PETTENKOFER OF MUNICH(1819-1901)-early
proponent of this concept. “Germ theory of disease
"or “single cause idea "in late 19 century
overshadowed the multiple cause theory.

10
ADVANCED MODEL OF THE TRIANGLE
OF EPIDEMIOLOGY
Causative Factors

TIME

Groups or Environment
populations and behaviour, culture
their physiological
characteristics factors ecological
elements 11
 WEB OF CAUSATION
• Suggested by- Mac Mahon and Pugh
• Considers all the predisposing factors of any type and
their complex interaction with each other.

12
 Changes in life style
Stress

Smoking
s e
a ke e rci Emotional stress
di nt
l ex
f f o o
s ica
o hy
nty P
Ple ko
f
a c Aging
L

HTN
Obesity

Hyperlipidemia Changes in the walls

of arteries
Coronary Occlusion

Coronary Myocardial ischemia Myocardial Ischemia

Atherosclerosis
Fig: Web of causation of MI
41

13
 NATURAL HISTORY OF DISEASE
It refers to the progress of a disease process in an
individual over time, in the absence of intervention.
• History of disease is a key concept in epidemiology.

14
15
 PRE PATHOGENESIS PHASE
• Disease agent has not entered man, but factors
favouring disease exist in the environment.

• What required is an interaction of these factors to

initiate the disease process.

Agent Host

Environment
16
 PATHOGENESIS PHASE
• Entry of disease agent in susceptible human host.

• Disease agent multiplies and induces tissue and

physiological changes.

• final outcome- recovery, disability or death.

• This phase may be modified by intervention measures

such as immunization, chemotherapy

17
 AGENT FACTORS
Substance living or non living , or a force, tangible or
intangible, the excessive presence or relative lack of which
may initiate or perpetuate a disease process.

1. Biological Agents – Infectivity Pathogenicity Virulence

2. Nutrient
3. Physical
4. Chemical
5. Mechanical
6. Absence or insufficiency
of a factor
7. Social

18
 HOST FACTORS
• Host - SOIL Disease agent –
SEED

Classified as
• Demographic
characteristics
• Biologic
• Social & Economic
• Lifestyle factors
19
 ENVIRONMENTAL FACTORS
• All that which is external to the individual
human host, living and non-living, and
with which he is in constant interaction.
-Macro-environment (external)
• Physical
• Biological
• Psycho social

20
 RISK FACTORS
• Where the disease agent is not
firmly established, the
aetiology is generally
discussed in terms of risk
factors.
• The term risk factor is used
by different authors with at
least two meanings-
 An attribute or exposure that is
significantly associated with
development of disease.
 A determinant that can be modified
by intervention, thereby reducing
the possibility of occurrence of
disease or other specified outcomes.
21
 RISK GROUPS
• Something for all but more for those in need- in
proportion to the need.
• Another approach developed and promoted by
WHO is to identify precisely the risk groups or
target groups in population by certain defined
criteria and direct appropriate action to them
first- risk approach.

22
 SPECTRUM OF DISEASE
• Graphic representation of variations in the
manifestations of disease.
• Infectious disease – gradient of infection

23
 ICEBERG OF DISEASE
• Disease in a community is compared to an
iceberg.

24
 CONCEPTS OF
CONTROL
The term disease control refers ongoing operation
aimed at reducing:
o The incidence of disease.
o The duration of disease and the consequently the
risk of transmission.
o The effect of infection including physical and
psychological complication.
o The financial burden to the community.

25
•DISEASE ELIMINATION: Reduction of case transmission to a
predetermined very low level or interruption in transmission.
E.g. measles, polio, leprosy from the large geographic region or
area.

• DISEASE ERADICATION: Termination of all transmission of

infection by extermination of the infectious agent through
surveillance and containment. “All or none phenomenon”. E.g.
Small pox.

26
• DISEASE MONITORING:

• Defined as “the performance and analysis of routine

measurement aimed at detecting changes in the environment
or health status of population.” e.g. growth monitoring of
child, Monitoring of air pollution, monitoring of water quality
etc.

• DISEASE SURVEILLANCE:

• Defined as “the continuous scrutiny of the factors that

determine the occurrence and distribution of disease and
other conditions of ill health.” E.g. Poliomyelitis surveillance
programme of WHO.

27
 CONCEPTS OF
PREVENTION
The goals of medicine are to
• Promote health,
• To preserve health,
• To restore health when it is
impaired
• And to minimize suffering and
distress.

These goals are embodied in the word "prevention"

28
• Actions aimed at eradicating, eliminating or
minimizing the impact of disease and disability,
or if none of these are feasible, retarding the
progress of the disease and disability.

• The concept of prevention is best defined in the

context of levels, traditionally called primary,
secondary and tertiary prevention. A fourth
level, called primordial prevention, was later
added.

29
Leavell’s Levels of Prevention
Stage of disease Level of prevention Type of response

Pre-disease Primary Prevention Health promotion and

Specific protection

Latent Disease Secondary prevention Pre-symptomatic

Diagnosis and treatment

Symptomatic Disease Tertiary prevention •Disability limitation for

early symptomatic disease
•Rehabilitation for late
Symptomatic disease

30
 PRIMORDIAL PREVENTION
• DEFINITION
“It is the prevention of the emergence or
development of risk factors in countries or population
groups in which they have not yet appeared.”
• INTERVENTION
The main intervention in primordial prevention is
through individual and mass health education.

31
 PRIMARY PREVENTION
• Primary
Goal: prevention can be defined as the action
taken priornumber
• Reduce to the onset
of new casesof disease, which removes
• the possibility that the disease will ever occur.
Rationale:
• By reducing exposure rates and increasing resistance, can reduce number
of new cases
• Target population:
• Those who are most likely to be exposed and/or could increase their
resistance
• Typical activities:
• Remove or reduce source of the risk
• Educate and make aware of disease risk
o Include behavioral changes to reduce exposure
• Improve general health
• Outcome measure: incidence of exposure; incidence of
disease
32
 SECONDARY PREVENTION
• Secondary
Goal: prevention can be defined as the action
• Reduce
which haltsnumber of new cases;of
the progress reduce number of at
a disease severe
itscases
incipient
• stage
Rationale:
and prevents complications.
• By reducing number of exposures and early disease that progress to more
severe disease, mortality and morbidity can be reduced

• Target population:
• Those who have been exposed to the disease-causing agent or have early
symptoms of the disease

• Typical activities:
• Screening for exposure and/or disease
• Post-exposure prophylaxis
• Early treatment to reduce impact of disease/reverse course

• Outcome measure: incidence of disease

33
 TERTIARY PREVENTION
Tertiary prevention can be defined as all measures
• available
Goal: to reduce or limit impairments and
• Reduce number
disabilities, of complications,
minimize deaths caused by existing
suffering
• departures
Rationale: from good health and to promote the
• By reducing
patients disease severity
adjustment to and increasing recovery,
irremediable can reduce number of
conditions.
premature deaths or complications

• Target population:
• Those who have disease and need treatment

• Typical activities:
• Treatment tailored to the patient
• Rehabilitation to promote recovery

• Outcome measure: incidence of death and long-

term disability
34
 MODES OF INTERVENTION
• Intervention is any attempt to intervene or interrupt the usual
sequence in the development of disease.
• Five modes of intervention corresponding to the natural
history of any disease are:

o Health Promotion
o Specific Protection
o Early Diagnosis and Adequate Treatment
o Disability Limitation
o Rehabilitation

35
 HEALTH PROMOTION
• It is the process of enabling people to increase control over
diseases, and to improve their health. It is not directed against
any particular disease but is intended to strengthen the host
through a variety of approaches(interventions):

o Health Education
o Environmental Modifications
o Nutritional Interventions
o Lifestyle and Behavioral Change

36
 SPECIFIC PROTECTION
• Some of the currently available interventions aimed at specific
protection are:
 immunization,
 use of specific nutrients,
 chemoprophylaxis,
 protection against accidents,
 protection from carcinogens,
 avoidance of allergens,
 control of specific hazards in general environment .eg air
pollution , noise control
 Control of consumer product quality and safety of foods,drugs
etc
37
 EARLY DIAGNOSIS AND TREATMENT
•A WHO defined early detection of health impairment as “the
detection of disturbances of homeostatic and compensatory
mechanism while biochemical, morphological, and functional
changes are still reversible.”

•Early detection and treatment are the main interventions of

disease control.
• Earlier a disease is diagnosed and treated the better it is from
the point of view of prognosis and preventing the occurrence of
further cases or any long-term disability.
•Ex – essential hypertension, cancer of cervix and Breast cancer

38
 DISABILITY LIMITATION

• Objective- is to prevent or halt the transition of the disease

process from impairment to handicap.

Sequence of events leading to disability & handicap:

• Disease → Impairment → Disability→ Handicap.

WHO defined these terms-

• Impairment: Loss or abnormality of psychological,
physiological/anatomical structure or function.
• Disability: Any restriction or lack of ability to perform an
activity in a manner considered normal for one’s age, sex, etc.
• Handicap: Any disadvantage that prevents one from fulfilling
his role considered normal. 39
 REHABILITATION
“combined and coordinated use of medical, social,
educational and vocational measures for training and
retraining the individual to the highest possible level of
functional ability”.
• Areas of concern in rehabilitation:
 Medical rehabilitation (restoration of function),
 Vocational rehabilitation (restoration of the capacity to earn a livelihood),
 Social rehabilitation ( restoration of family and social relationships),
 Psychological rehabilitation (restoration of personal dignity and
confidence).

40
 CHANGING PATTERN OF
DISEASE
• Although diseases have not changed significantly
through human history, their patterns have.
• Every decade produces its own patterns of disease.

41
Spanish flu

42
 EPIDEMIOLOGICAL
TRANSITION.
• A characteristic shift in the disease pattern of a
population as mortality falls during the
demographic transition: acute, infectious
diseases are reduced, while chronic,
degenerative diseases increase in prominence,
causing a gradual shift in the age pattern of
mortality from younger to older ages. (Omran
1970)

43
DEVELOPED COUNTRIES
• Causes of diseases and deaths
have shifted from infectious to
chronic diseases.
Common disease- HEART DISEASE - 23.81%
CANCER-22.95%
CVS- 5.16% .
These 3 together- constitutes about 51.92% of deaths in
US.
OTHERS- Alzheimer's disease, lung cancer, environmental
health problems, and microbial diseases

44
• DEVELOPING COUNTRIES
• Nation with a low level of material well-being.

• In a typical developing country about 40%of

death are from infectious ,parasite, and
respiratory diseases compared with about
8%in developed countries.

• In India ,as in other developing countries ,most

death result from infectious and parasite
disease, abetted by malnutrition.
45
46
47
 DISEASE CLASSIFICATION
• A system of classification was needed whereby diseases could
be grouped according to certain common characteristics ,
that would facilitate the statistical study of disease
phenomena.
• JOHN GRAUNT in 17th century- in his study of Bills of mortality
– arranged diseases in an alphabetic order.

48
 ICD CLASSIFICATION
• International classification of disease (ICD)by WHO -
accepted for national and international use.

• Revised once in 10 years.

• The ICD is a classification system developed collaboratively

between the World Health Organization WHO) and 10
international centers so that the medical terms reported by
physicians, medical examiners, and coroners on death
certificates can be grouped together for statistical purposes

49
ICD-10 ARRANGED IN 21 DIFFERENT CHAPTERS

50
 Why we need disease???
• HAEMOCHROMATOSIS - BUBONIC PLAGUE

• DIABETES - YOUNGER DRYAS

• FAVISM - MALARIA

Natural selection is maintaining this

genetic defect because it had conferred
some benefit in the past.

51
 CONCLUSION
• Understanding disease pathology is the
first step towards formulating preventive
measures.

• As a dentist or public health worker it is

our primary responsibility for the
prevention of diseases in community as
well as individual.

52
 REFERENCES
• Park, Park’s Textbook of Preventive &Social Medicine, 22nd
Edition, Jabalpur: Banarsidas Bhanot,2013.
• Soben Peter. Essentials of Public Health Dentistry. 4th ed.
New Delhi: Arya Publising House; 2013.
• Epidemiology, L. Gordis, Fourth ed, 2009, Saunders
• Moalem, S., & Prince, J. (2007). Survival of the sickest: A
medical maverick discovers why we need disease. New York:
William Morrow.

53
  
 
Theories  Of  Disease  Causation  
Understand  the  main  concept  of  these  theories.  

Germ  theory    
In  the  second  half  of  19th century  
Proposed  by  Robert  Koch  and  Louis  Pasteur  (discovery  of  bacteria).    

It  states  that  every  human  disease  is  caused  by  a  microbe  or  germ,  which  is  specific  for  that  
disease  and  one  must  be  able  to  isolate  the  microbe  from  the  diseased  human  being.  Once  you  
remove  the  microbe  from  this  person,  he  will  be  cured.  

One  to  one  relationship  between  causal  agent  and  disease.    

Disease agent Man Disease

 
 
The  Epidemiological  Triad  

The  European  noticed  that  the  

prevalence  of  TB  reduced  even  
though  there  wasn’t  any  
preventive  methods  or  treatment  
for  TB,  so  they  start  thinking  
there  are  other  causes  or  factors  
beside  the  agent.  So  they  
announced  that  the  first  theory  
was  wrong.  
 

 
  

Example  

Not  everyone  exposed  to  tubercle  bacteria  develops  tuberculosis  but  the  same  exposure  in  an  
undernourished  or  immunocompromised  person  may  result  in  clinical  disease  and  exposure  
occurs  more  in  overcrowding.    

So  if  the  immunity  and  nutritional  status  of  that  person  is  good,  he  won’t  develop  the  disease,  
that’s  why  the  interaction  of  these  3  factors  (host,  agent  and  environment)  are  important  in  
order  to  develop  the  disease.  

Epidemiological  Tetrad    
In  addition  to  HOST,  AGENT  and  ENVIRONMENT,  one  more  factor  TIME  factor  is  added.    

TIME  accounts  for  incubation  periods,  life  expectancy  of  the  host  or  pathogen,  duration  of  the  
course  of  illness.    

 
  

The  “BEINGS”  Model  of  Disease  Causation    

A  complex  interplay  of  nine  different  factors    

•   Biological  factors  innate  in  a  human  being,    

•   Behavioural  factors  concerned  with  individual  lifestyles,  Ex.  physical  or  sedentary  lifestyle  
•   Environmental  factors  as  physical,  chemical  and  biological  aspects  of  environment,    
•   Immunological  factors,    
•   Nutritional  factors,    
•   Genetic  factors,    
•   Social  factors,    
•   Spiritual  factors  and    
•   Services  factors,  related  to  the  various  aspects  of  health  care  services.  

The  Theory  of  “Web  of  Causation”    

•   Suggested  by  MacMohan  and  Pugh.    
•   The  various  factors  (e.g.  hypercholesterolemia,  smoking,  hypertension)  are  like  an  
interacting  web  of  a  spider.    
•   Each  factor  has  its  own  relative  importance  in  causing  the  final  departure  from  the  state  of  
health,  as  well  as  interacts  with  others,  modifying  the  effect  of  each  other.    
•   Ideally  suited  in  the  study  of  chronic  disease,  where  the  agent  is  often  not  known  and  
disease  is  the  outcome  of  interaction  of  multiple  factors.    
•   This  model  of  disease  causation  considers  all  predisposing  factors  of  any  type  and  their  
complex  interrelationship  with  each  other.  

Development  of  MI:  all  these  factors  (more  than  10)  contribute  to  the  development  of  MI.  

 
 

 
  

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.  

The  “triad”  as  well  as  the  “web”  theory  does  not  adequately  cover  up  this  differential.  
To  explain  such  relative  contribution  of  genetic  and  environmental  factors,  the  “wheel”  theory  
has  been  postulated.  

we  have  3  types  of  environmental  factors,  the  higher  the  affect  of  one  of  them  the  bigger  the  
wheel.  

 
According  to  the  type  of  the  disease  the  wheel  cycle  will  change  the  size  depending  on  the  
largest  contribution  of  such  component  in  developing  a  disease.  
  

Natural  History  of  Disease    

Definition    

Natural  history  of  disease  refers  to  the  progress  of  a  disease  process  in  an  individual  over  
time,  in  the  absence  of  intervention.  We  do  the  prevention  according  to  the  history  of  the  
diease.  

The  process  begins  with  exposure  to  or  accumulation  of  factors  capable  of  causing  disease    

without  medical  intervention,  the  process  ends  with:  

•   Recovery.  Like  flu  for  example,  most  people  recover  from  it  when  taking  medications.  
•   Disability.  
•   Death.  

Why  it  is  important?    

It  is  one  of  the  major  elements  of  descriptive  epidemiology.    

Understanding  the  progress  of  disease  process  and  its  pathogenetic  chain  of  events  is  must  for  
the  application  of  preventive  measures.  So  if  the  patient  develops  a  certain  disease,  we  will  be  
able  to  know  the  signs  and  the  duration  of  it.  

Which  Design  is  the  Best?    

The  natural  history  of  disease  is  best  established  by  cohort  studies.    

As  these  studies  are  costly,  understanding  of  the  natural  history  of  disease  is  largely  based  on  
other  epidemiological  studies,  such  as  cross-­‐‑sectional  and  retrospective  studies,  undertaken  in  
different  population  settings.    

•   What  the  physician  sees  in  the  hospital  is  just  an  "episode"  in  the  natural  history  of  disease.    
•   The  epidemiologist,  by  studying  the  natural  history  of  disease  in  the  community  setting  is  in  a  
unique  position  to  fill  the  gaps  in  the  knowledge  about  the  natural  history  of  disease    

 
  

Schematic  Diagram  of  The  Natural  history  of  disease  in  a  patient  
Why  ?  
It  is  framework  to  understand  the  pathogenic  chain  of  events  for  a  particular  disease,  and  for  
the  application  of  preventive  measures.  
 

Consists  of  two  phases    

 
 
 
 

 
  

 
 

Pre-­‐‑pathogenesis  phase  

This  refers  to  the  period  preliminary  to  the  onset  of  disease  in  man.    

The  disease  agent  has  not  yet  entered  man,  but  the  factors  which  favor  its  interaction  with  
the  human  host  are  already  existing  in  the  environment.    

This  situation  is  frequently  referred  to  as  “man  exposed  to  the  risk  of  disease”.    

Pathogenesis  phase    
This  phase  begins  with  entry  of  the  disease  “agent”  in  the  susceptible  human  host.    

After  the  entry,  agent  multiplies  and  induces  tissue  and  physiological  changes,  the  disease  
progresses  through  the  period  of  incubation  and  later  through  the  period  of  early  and  late  
pathogenesis.    

The  final  outcome  of  the  disease  may  be  recovery,  disability  or  death.    

In  chronic  diseases,  the  early  pathogenesis  phase  is  less  dramatic  and  is  also  called  as  pre-­‐‑
symptomatic  phase.    

During  pre-­‐‑symptomatic  stage,  there  is  no  manifest  disease.  The  pathological  changes  are  
essentially  below  the  level  of  the  “clinical  horizon”.    

The  clinical  stage  begins  when  recognizable  signs  or  symptoms  appear.    

By  the  time  signs  and  symptoms  appear,  the  disease  phase  is  already  well  advanced  into  the  
late  pathogenesis  phase.    

 
  

Spectrum  of  disease  and  Iceberg  Phenomenon  

Spectrum  of  disease:    

It  is  a  graphic  representation  of  variations  in  the  manifestations  of  disease.    

At  the  one  end  of  disease  spectrum  are  sub-­‐‑clinical  infections  which  are  not  ordinarily  
identified,  and  at  the  other  end  are  fatal  illnesses.    

In  the  middle  of  spectrum  lie  illnesses  ranging  in  severity  from  mild  to  severe.    

These  different  manifestations  are  the  result  of  individuals’  different  states  of  immunity  and  
receptivity.    

Iceberg  of  disease:    

‫ ﺞﻠﺛﻟﺍا‬ ‫ ﺓةﺭرﺎﺑﻋ‬ ‫ ﻥنﻋ‬ ‫ ﺽضﺭرﻣﻟﺍا‬ ‫ﻪﮫﻠﻛ‬،٬  ‫ ﻲﻠﻟﺍا‬ 

‫ ﺕتﺣﺗ‬ ‫ ﺔﻳﯾﻭوﻣﻟﺍا‬ ‫ ﺍاﺫذﻫﮬﮪھ‬ ‫ ءﺯزﺟﻟﺍا‬ ‫ ﻲﻠﻟﺍا‬ 
‫ ﻪﮫﻓﻭوﺷﻧﺎﻣ‬ ‫ ﻥنﻣ‬ ‫ ﺽضﺭرﻣﻟﺍا‬ ‫ ﻲﻠﻟﺍاﻭو‬ ‫ ﺎﻬﮭﻗﻭوﻓ‬ 
‫ ﻱيﺫذﻫﮬﮪھ‬ ‫ ﺽضﺍاﺭرﻋﺃأ‬ ‫ﺽضﺭرﻣﻟﺍا‬،٬  ‫ ﻲﻠﻟﺍاﻭو‬ 
  clinical  horizon‫ ﻡمﻬﮭﻧﻳﯾﺑ‬ ‫ ﻭوﻫﮬﮪھ‬ ‫ﻝلﺍا‬

 
  

Spectrum  of  disease    

Spectrum  of  disease  presents  challenges  to  the  clinician  and  to  the  public  health  worker.    

WHY?    

•   Because  of  the  clinical  spectrum,  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  remain  asymptomatic.    
•   For  the  public  health  worker,  the  challenge  is  that  persons  with  undiagnosed  infections  may  be  
able  to  transmit  them  to  others.    

Prevention  of  disease  

Prevention  is  the  process  of  intercepting  or  opposing  the  “cause”  of  a  disease  and  thereby  the  
disease  process.    

Why  is  it  important?  1-­‐‑  Individual  benefit:  increases  the  survival  rates  and  productivity  of  the  
person.  

2-­‐‑  Economical  benefit:  preventing  the  disease  is  less  costly  than  treating  the  complications  of  it  
(referring  the  patient  to  more  than  one  clinic).  

Successful  prevention  depends  on:    

1.   Knowledge  of  causation  
2.   Dynamics  of  transmission    
3.   Identification  of  risk  factors  (smoking,  Hypertension,  physical  in  activity)  and  risk  groups  
(Family  history  of  colon  cancer,  you’ll  do  a  check-­‐‑up  for  the  family  to  reduce  the  incidence  of  
the  disease)    
4.   Availability  of  prophylactic  or  early  detection  and  treatment  measures    
5.   Organization  to  apply  these  measures    
6.   Continuous  evaluation    

Levels  Of  Prevention    

• Primordial  
prevention    
• Primary  prevention  
• Secondary  prevention  
 
• Tertiary  prevention    
  

Primordial  prevention    
It  is  the  prevention  of  the  emergence  or  development  of  risk  factors  in  population  groups  in  
which  they  HAVE  NOT  yet  appeared.    

For  example,  many  adult  health  problems  (e.g.,  obesity  and  hypertension)  have  their  early  
origin  in  childhood,  so  efforts  are  directed  towards  encouraging  children  to  adopt  healthy  
lifestyles  (  e.g,  physical  exercise,  healthy  dietary  habits  etc.)  so  the  prevalence  of  HTN  and  
obesity  will  reduce  when  they  get  older.  

The  main  intervention  in  primordial  prevention  is  through  individual  and  mass  education.    

Primary  Prevention    
It  can  be  defined  as  “  action  taken  prior  to  the  onset  of  disease,  which  removes  the  possibility  
that  a  disease  will  ever  occur.  They  are  at  high  risk  but  they  don’t  have  the  disease  yet,  so  we  
interfere  with  this  stage  to  prevent  the  disease  from  happening.  Elimination  or  modification  of  
“risk  factors”    

It  signifies  intervention  in  the  pre-­‐‑pathogenesis  phase  of  a  disease.    

The  concept  of  primary  prevention  is  now  being  applied  to  the  prevention  of  chronic  diseases  
such  as  coronary  heart  disease,  hypertension  and  cancer  based  on  elimination  or  
modification  of  "risk-­‐‑factors"  of  disease.      

Two  types  of  strategies  

Population  (  mass  )  strategy   High  risk  strategy  
•   Includes  identification  of  “High  risk  
•   directed  at  whole  population   groups”  in  the  population  and  bring  
irrespective  of  the  individual  risk  levels.   preventive  care  to  these  risk  group.  
•   directed  towards  socio-­‐‑economic,   •   e.g.,  People  having  the  family  history  of  
behavioral  and  lifestyle  changes   Hypertension,  allergic  disease,  Diabetes  .  

 
 
  

Secondary  prevention    
Defined  as  “action  which  stop  the  progress  of  a  disease  at  its  initial  stage  and  prevents  
complications”.    

It  is  applied  in  the  early  pathogenesis  stage  of  disease.    

•   It  reduces  the  prevalence  of  the  disease  by  shortening  its  duration.    
•   It  may  also  protect  others  in  the  community  from  acquiring  the  infection  and  thus  provide,  at  
once,  secondary  prevention  for  the  infected  individuals  and  primary  prevention  for  their  
potential  contacts.  

The  specific  interventions  used  is  :  Early  diagnosis  and  treatment.    

Early  detection  of  health  impairment  is  defined  as  “  the  detection  of  disturbances  of  
homoeostatic  and  compensatory  mechanism  while  biochemical,  morphological  and  
functional  changes  are  still  reversible.    

e.g.  ,  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:  

1.   prevent  or  delay  death,  Ex.  chemotherapy  treatment  for  cancer  patients.  
2.   reduce  or  limit  the  impairments  and  disabilities,  
3.   minimize  suffering  and  
4.   promote  the  subject’s  adjustment  to  incurable  conditions.    

 
  

Tertiary  prevention  has  two  types  of  approaches  

Disability  Limitation   Rehabilitation  

These  include  all  measures  to  prevent  the   It  is  defined  as  the  combined  and  
occurrence  of  further  complications,   coordinated  use  of  medical,  social,  
impairments,  disabilities  and  handicaps  or   educational  and  occupational  measures  for  
even  death.     training  and  retraining  the  individual  to  the  
highest  possible  level  of  functional  ability.  

   

•   Complete  rest,  morphine,  oxygen  and   •   Establishing  schools  for  blinds    

streptokinase  is  given  to  a  patient  of   •   Provision  of  aids  for  the  handicapped    
Acute  MI,  to  prevent  death  or   •   Reconstructive  surgery  in  leprosy    
complications  like  arrhythmias  /  CHF.     •   Muscle  re-­‐‑education  and  graded  
•   Application  of  plaster  cast  to  a  patient   exercises  in  neurological  disorders    
who  has  suffered  Colle’s  fracture,  is  done  
to  prevent  complications  and  further  
disability  like  mal-­‐‑union  or  non-­‐‑union  

This  picture  is  for  your  reading  only.  

 
 
 
 
 
 
 
  
  LEVEL  OF   PHASE  OF   TARGET  
PREVENTION   DISEASE  
  Primordial   Underlying   Total  population  
condition  leading   and  selected  
to  causation   groups  
  Primary   Total  population,  
Specific  causal   selected  groups  
factors   and  healthy  
individuals  
  Secondary   Early  stage  of  
patients  
disease  
  Tertiary   Late  stage  of  
patient  
disease  
 

 
   
 Summary  
Theories  of  Disease  Causation  
1)   Germ  theory:  Every  human  disease  is  caused  by  a  microbe  or  germ,  which  is  specific  for  that  
disease  and  one  must  be  able  to  isolate  the  microbe  from  the  diseased  human  being.    
2)   The  Epidemiological  Triad:  The  triad  consists  of  an  external  agent,  a  host  and  an  environment  
in  which  host  and  agent  are  brought  together,  causing  the  disease  to  occur  in  the  host  
3)   Epidemiological  Tetrad:  In  addition  to  HOST,  AGENT  and  ENVIRONMENT,  one  more  factor  TIME  
factor  is  added.  
4)   “BEINGS”  Model:  A  complex  interplay  of  nine  different  factors  
5)   “Web  of  Causation”:  The  various  factors  are  like  an  interacting  web  of  a  spider,  that  cause  the  
disease  and  modify  the  effect  of  each  other  each  other.    
6)   Wheel  theory:  To  explain  such  relative  contribution  of  genetic  and  environmental  factors  
 

Natural  History  of  Disease    

♦   Is  the  progress  of  a  disease  process,  in  an  individual  over  time  in  the  absence  of  intervention.  
♦   Without  medical  intervention,  the  process  ends  with:    
1)   Recovery.      2)Disability.    3)Death.  
♦   The  natural  history  of  disease  is  best  established  by  cohort  studies    
 
Schematic  Diagram  of  the  Natural  history  of  disease  in  a  patient  
Phases   Pre-­‐‑pathogenesis  phase   Pathogenesis  phase  
Definition   the  disease  progresses  through  the  period  of  
the  period  preliminary  to  the  onset  of  
incubation  and  later  through  the  period  of  early  
disease  in  man.  
and  late  pathogenesis.  
Begins   When  the  factors  already  existing  in  
entry  of  the  disease  “agent”  into  the  human  
the  environment.  
Ends   When  the  disease  agent  enters  the  
Ends  with  death,  disability  or  recovery  
human  
 Spectrum  of  disease:    
♦   It  is  a  graphic  representation  of  variations  in  the  manifestations  of  disease  
 
Prevention  of  disease  
♦   Prevention  is  the  process  of  intercepting  or  opposing  the  “cause”  of  a  disease  and  thereby  
the  disease  process.  
  Levels  Of  
Definition     Intervention    
Prevention  
It  is  the  prevention  of  the  emergence  or  
Primordial   individual  and  mass  education  
development  of  risk  factors  in  population  groups  
prevention    
in  which    they  HAVE  NOT  yet  appeared.  
Through:  
Primary   action  taken  prior  to  the  onset  of  disease  
♦   Population  strategy  
Prevention    
♦   High  risk  strategy  
“action  which  stop  the  progress  of  a  disease  at  its  
Secondary  
initial  stage  and  prevents  complications”   Early  diagnosis  and  treatment.  
prevention  
 
Through:    
all  measures  undertaken  when  the  
Tertiar  y   ♦   disability  limitation  
disease  has  become  clinically  manifest  or  advanced  
prevention   ♦   rehabilitation  
 
 
 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

3
• 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.

4
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.

5
 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.

6
 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

7
Typical course of infectious disease
TIME

Susceptible Subclinical Death

Disease
Host
Clinical
Disease
No
infection
Recovery

Incubation
period
Exposure Onset

8
 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.

9
 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.

10
 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

11
 ECOLOGICAL THEORY

• Around 463 BC, HIPPOCRATES was the

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

12
 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.

13
 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

14
 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
1–15
 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.

16
 Epidemiologic Triad

Disease is the result

of forces within a
dynamic system
consisting of:

agent of infection
host
environment

17
 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

18
 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)

19
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
20
Web of Causation for the Major Cardiovascular Diseases

21
22
 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

23
 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

24
 Assignment
Differentiate between disease Elimination and
Eradication with real life examples.

25
 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

26
 “Iceberg” concept of infectious disease in
populations

DEATH
CLINICAL
DISEASE SEVERE
DISEASE

SUB CLINICAL MILD ILLNESS

DISEASE

INFECTION WITHOUT
CLINICAL ILLNESS

EXPOSURE WITHOUT INFECTION

27
 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

28
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

30
 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.
31
 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

32
 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.

33
 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

34
 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.

35
36
PRIMARY SECONDARY TERTIARY

37
38
39
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

40
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
41