Natural History of

Disease
Background
 Infectious disease epidemiology
 the occurrence of infectious disease in a
given host is dependent on the presence
of disease in other members of the
population and the length of time that
infected hosts are able to transmit
disease to others
 understanding these characteristics of a

disease allow us to develop rational

measures to control disease
 Definition & Stages
• Definition ; The course of a disease from onset
(inception) to resolution.

• Stages
Progress to a fatal termination
Stage of
Pre-symptomatic Clinically
pathologic Remission and relapses
stage manifest disease
onset
Regress spontaneously,
leading to recovery

Risk Factors Precursors Effect of Treatment Prognostic factor

 Risk factor
 Risk factor; An aspect of personal behavior or life
style, an environmental exposure, or an inborn or
inherited characteristic, that, in the basis of
epidemiologic evidence, is known to be associated
with health-related condition (s) considered important
to prevent.
– Risk marker; increased probability of a specified
outcome; not necessarily a causal factor
– Determinant; can be modified by intervention,
thereby reducing the probability of occurrence of
disease or other specified outcomes
 The Natural history of disease in a
patient
Preclinical Phase Clinical Phase

(A) (P) (S) (M) (D) (T)

A ; Biologic onset of disease

P ; Pathologic evidence of disease if Sought
S ; Signs and symptoms of disease
M ; Medical care sought
D ; Diagnosis
T ; Treatment
Gordis L. Epidemiology. WB Saunders Company. 1996
 THE NATURAL HISTORY OF A DISEASE
STIMULUS to
HOST REACTION RECOVERY
the HOST
interrelation of
Agent, Host and Latent Period (Pre- Symptoms, with or without Defects,
Environmental symptomatic) Signs(Clinical) Disability
factors

PREPATHOGE
PERIOD OF PATHOGENESIS
NESIS

Health
Promotion Disability Limitation
Specific Early Diagnosis and Prompt
Protection Treatment,
Rehabilitation

PRIMARY SECONDARY
TREATMENT TERTIARY PREVENTION
PREVENTION PREVENTION
(Leavell's Level of Application of Preventive Medicine)
 TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious Non-infectious

Exposure Onset
 Latent period
the time interval from infection to
development of infectiousness
 Infectious period
the time during which time the host can infect
another susceptible host
 Non-infectious period
the period when the host’s ability to transmit
disease to other hosts ceases
 Incubation period
the time interval between infection to
development of clinical disease
 e.g : Chicken pox
 an infectious disease caused by the
varicella-zoster virus
 the latent period for chicken pox is shorter
than the incubation period, so a child with
chicken pox becomes infectious to others
before developing symptoms
 TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious Non-infectious

Exposure Onset
 Other examples?
 HIV (AIDS)
 latent period relatively short
 infectious period occurs (many years) before the
onset of symptoms
 TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious

Exposure Onset
e.g : Malaria
 caused by protozoan parasites of the genus
Plasmodium
 the stages of the parasite that are infective
to mosquitoes occur about 10 days after the
development of symptoms
 latent period is around 10 days longer than
the incubation period, so early treatment of
symptoms could have an important effect on
transmission
Natural history of disease
TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious

Exposure Onset
 Latent Period of Chronic
Disease
Definition; "Interval between exposure to a disease-
causing agent and the appearance of manifestations of
the disease"
cf. incubation period in infectious disease

1) brief exposure

Two conditions

2) prolonged or continuous exposure

 Primary Prevention

 'Preventing the occurrence of disease or injury by

modifying risk factors.'
 'Various aspects are considered to produce effective
primary prevention program. Especially, advancing
knowledge of disease causation must be required.‘
Primary Prevention
 ** Guidelines for effective prevention programs(RB
Wallace, GD Everett,1986)
– Programs must be based on scientific evidence.
– Prevention programs should be supported by effective
data system.
– Programs should be flexible.
– Programs must be sensitive to ethical issues.
– Programs should be targeted to the recipients most in
need.
– Programs should muster a variety of community
resources.
– Effective prevention requires legislative action and
social policy decisions.
– Programs should be continuous.
Primary Prevention

 General health promotion

– 'Proper nutrition, mental hygiene, adequate housing, and appropriate
balance between work and play, est and exercise, and useful and
productive place in society, are among the best recognized factors
ontributing to maintenance of optimum health.(Commission on Chronic
illness, USA, 1957)‘
 Specific protection
 Health Promotion
– 'Health promotion is any combination of educational, organizational,
economic, and environmental supports for behavior and conditions of
living conducive to health (LW Green, 1992).'
 Criteria for the Development of Health
Promotion and Education Programs
 A health promotion program should address one or more risk
factors which are carefully defined, measurable, modifiable,
and prevalent among the members of a chosen group, factors
which constitute a threat to the health status and the quality of
life of target group members.
 A health promotion program should reflect a consideration of
the special characteristics, needs, and preferences of its target
groups(s)

From APHA Technical Report

 Criteria for the Development of Health
Promotion and Education Programs

 health promotion programs should include interventions which will

clearly and effectively reduce a targeted risk factor and are appropriate
for a particular setting
 A health promotion program should identify and implement
interventions which make optimum use of available resources.
 From the outset, a health promotion program should be organized,
planned, and implemented in such a way that its operation and effects
can be evaluated.
Secondary Prevention

 'Early detection and intervention, preferably before the

condition is clinically apparent, and has the aim of
reversing, halting, or at least retarding the progress of a
condition.‘

 'It sometimes happens that a patient first becomes aware

of a disease when it is already too late for it to be
successfully treated.‘
Tertiary Prevention

 'Minimizing the effects of disease and disability

by surveillance and maintenance aimed at
preventing complications and premature
deterioration'

 Medical rehabilitation

 Social rehabilitation
 THE NATURAL HISTORY of ANY DISEASE of MAN

 Reaction of the HOST to the STIMULUS 

Interrelations of Agent, Host, and Environmental Factor Pro-
Early  Discernible  Advenced  Convalence 
duction of STIMULUS 
pathogenesis early lesions disease
Prepathogenesis Period Period of Pathogenesis

HEALTH PROMOTION
SPECIFIC
PROTECTION
EARLY DIAGNOSIS AND
REHABILITA-TION
PROMPT TREATMENT

Health education DISABILITY

Good standart of nutrition LIMITATION Provisions of hospital
Case-finding measures,
adjusted to developmental Adequate treatment to and community facilities
Use of specific immunizations individual and mass
phases of life arrest the disease process for retraining and
Attention to personal hygiene Screening surveys
Attention to personality and to prevent further education for maximum
Use of environmental sanitation Selective examinations
development complications and use of remaining
Protection againts occupational Objectives:
Provision of adequate housing, sequelae capacities
hazards To cure and prevent disease
recreation, and agrreable Provision of facilities to Education of public and
Protection from accidents processes
working conditions limit disability and to industry to utilize the
Use of specific nutrients To prevent the spread of
Marriage counseling prevent death rehabilitated
Protection from carcinogens communicable diseases
Genetics As full employment as
Avoidence of allergens To prevent complications and
Periodeic selective examinatios possible
sequelae
Work therapy in hospital
To shorthen period of disability
Use of sheltered colony

Primary prevention Secondary Prevention Tertiary Preverntion