Theories and levels of disease

occurrence
Ashenafi Shumye (BSc.PH, MPH)
Lecturer in Public Health Department
College of Health Sciences
Mekelle University

1
1. Introduction
• Communicable diseases continue to account for
a major proportion of disease burden

• Occur in epidemic forms

• The problem is exacerbated by:

• Poor socio-economic status
• Poor personal and environmental hygiene
• Inadequate health service coverage, etc.

2
2. Components of Infectious
Disease Process
• Infectious diseases result from the interaction
between the infectious agent, host/reservoir and
environment.
Host

Agent Environment

Fig 2. Components of infectious diseases

3
 Cont…
• Agent: An agent is a factor whose presence or
absence, excess or deficit is necessary for a
particular disease or injury to occur
• An infectious micro-organism depends on:
– Pathogenicity, is the ability of a pathogen to produce
an infectious disease in an organism.
– infectivity, the ability of a pathogen to establish an infection
– infective dose,
– immunogenicity, is the ability of a particular substance, such as
an antigen or epitope, to provoke an immune response in the body
of a human or animal.
– Virulence
4
• Host: Related to human factors.
– Influences individual’s exposure, susceptibility or
response to a causative agent, and it depends on:
• Age, - gender,
• race, - habits,
• sexual activities, - immunization,
• contraception, - diet,
• nutrition, -etc.

5
 Cont….

• Environment: encompasses all extrinsic of the

human host
– Physical: describes the geography and climate,
tropical/temperate, urban/rural;

– Biological: made up of plants, animals, and other life

forms;

– Socioeconomic: includes factors like housing,

sanitation, population density, crowding, education,
occupation, public health resources.

6
3. Causal Concepts of Disease
• Not all associations between exposure and
disease are causal.

• A cause: A can be an event, a condition, a

characteristics or a combination of factors
– that preceded the disease and
– without which the disease would not occur.

7
 Casual …
• In past times
– There were an assumption of one-to-one
correspondence between the observed cause and
the effect.
– One factor is necessary and sufficient

• At present
– The understanding is that the cause of any effect
must consist a constellation of components that
act in concert.
– There is necessary and sufficient causes
8
 Con…
• If disease does not develop without the
factor, then the causative factor is
“necessary”.
• Necessary cause is a factor that is necessary
(or with out which) the disease does not
occur or exist
• No specific factor is sufficient to produce a
disease.

9
 Cont….
• A “sufficient cause” : which means a
complete casual mechanism
– defined as a set of minimal conditions and
events that inevitably produce disease;

• The occurrence of all of the conditions or

events is necessary.

• For example,
Tobacco smoking is a cause of lung cancer, but by
itself it is not a sufficient cause.
10
 Cont…
• If a single factor alone become sufficient to
develop the disease, then we term the
causative factor as both “Necessary” and
“sufficient”.

• Example:
– Tubercle bacilli is a necessary factor for TB

– Rabies virus is sufficient for developing

clinical rabies
11
 Evolution in Epidemiology
Multi-level causality (21st Century): focus on risk-
factors as well as causal pathways at the societal level and with
pathogenesis at the molecular level.(postmodern)

Chronic disease era (Modern

Epidemiology): focus on risk-factor at individual level

Germ theory: infectious disease era(traditional)

Miasma theory: focus on environment; the theory

that all disease was due to bad air–contaminations(miasma) (traditional)
12
 4. Disease Models
• How do diseases develop?
• Visualizes disease and injury etiology.
• There are number of disease models
• Three best known
1.Epidemiological triangle model
2.Web causation
3.The wheel causation model

13
1. Epidemiologic triangle and
triad (balance beam).

Traditional model of infectious disease

causation
Agent Agent Host

Host Environment
Environment
Epidemiologic triangle Balance beam

14
 Cont…
• From the perspectives of epidemiological
triad, the host, agent, and environment can
coexist harmoniously.
• Disease and injury occur only when there is
interaction or altered equilibrium between
them.
• Disruption of any link can also prevent
disease

15
2 Multi-causality of Diseases
• Web casual model= Spider's web
• Developed in response to the idea that an infectious
agent is a unique and sufficient cause of a disease.

• In the traditional model, each cause is seen as

necessary and sufficient in itself to produce the effect.

• However a specific necessary disease agent is not

recognized for non-infectious diseases.

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 Cont….
• In this approach, the causes of disease are
considered to be agents, exposures, or risk
factors.

• The factors may include microbes, chemicals,

nutrients, physiologic, genetic characteristics,
as well as behaviors, mental states, race or
socioeconomic status.

17
 Con….
• An agent is considered to be necessary but not
sufficient causes of a disease b/s the conditions of the
host and the environment must be optimal for a
disease to develop.

• The requirement that more than one factor be

present for disease to develop is referred to as
multiple causation or multi-factorial etiology.
• These factors are related to agent, host and
environment
18
 Cont…
An example of three sufficient causes of a
disease
I II III

U U U

A B A E B E

Assume that these three causes are operating in the diagram

Without U, there is no disease. U is considered as necessary

cause, but all disease is not due to U alone.

E causes disease through two mechanisms, II and III, all diseases

arising from II and III are due to E.

No component cause acts alone, the factors interact with their

complementary factors to produce disease
19
 3. Wheel model of infectious diseases
Social
Agent environment

Host Agent

Genetic
Agent
core
Physical
(Humans) environment
Biologic
environment Agent

The interaction of humans with infectious agents and their environment, a

person’s state of health represents a dynamic equilibrium – a balance of
forces. 20
 The agent
1. Nutritive element
2. Chemical element
3. Physical element like radiation
4. Infectious agent

21
 Host factors
• Influences
– Exposure
– Susceptibility
– Response to agents
• Includes
– Genetic factor
– Physiologic factor (pregnancy, puberty, stress )
– Immunologic factor,
– Human behaviour, Hygienic….
• Host factor results from the interaction of genetic
endowment with environment. 22
 Environmental factors
• It is extrinsic factor which affect the agent and
the agent for exposure
• Influence the existence
– Exposure
– Agent
– susceptibility
• Includes
– Biological event (agent, reservoir, vector)
– Social environment (socioeconomic, poletical)
– Physical environment
23
• Generally we can classify cause of a disease in
to two
1. Primary cause or etiologic agent (necessary)
2. Risk factor (aggravating, predisposing factors or
contributing factors)

24
 Risk factors
• Risk factor is any factor associated with an
increased or decreased occurrence of a
disease.
• It could be
– Factor related to the agent (strain difference…)
– Factor related to the human host (immunity….)
– Factors related to the environment (over
crowding, lack of ventilation….)

25
 Risk factors
• may be classified as
– 1. Factors susceptible to change
• Smoking habit, alcohol drinking habit,
• It is a factor epidemiology is interested in
– 2. Factors not amenable to change
• Age, sex, family history

26
 Association vs. Causation

• Does exposure A cause disease B?

• First, find out if variables associated
• Then use causal inference methods to
assist

27
 Association vs. Causation
• Association in simply an identifiable relationship
between an exposure an exposure and disease
e.g. Coronavirus is isolated more frequently from individuals
with diarrhea than those without
• Implies that exposure might cause disease
• Exposures associated with a difference in disease risk
are often called “risk factors

28
 Association vs. Causation
 Causation implies that there is a true mechanism
that leads from exposure to disease
– e.g., long-term heavy smoking causes myocardial
infarction
 
 Finding an association does not make it causal
– e.g., hospital stays are associated with an increased
mortality rate, but this does not mean they cause death

29
 Bradford-Hill Criteria (1968)
1. Strength of association
2. Consistency
3. Specificity
4. Temporality
5. Biological gradient (dose response)
6. Plausibility
7. Coherence
8. Experimental evidence
9. Analogy

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 Strength of association
Strong associations are more likely to be causal
than weak ones.

• Smoking > 20 cigarettes/d laryngeal cancer (RR 20)

• Not all strong associations are causal
Downs syndrome and birth rank (confounder)
• Weak associations do not rule out causality
passive smoking and lung cancer (RR 1.4)

31
 Strength of Association

Relative risk Interpretation

1.1-1.3 Weak
1.4-1.7 Modest
1.8-3.0 Moderate
3-8 Strong
8-16 Very strong
16-40 Dramatic
40+ Overwhelming 32
 Consistency of Effect
• Relationships that are demonstrated in
multiple studies are more likely to be causal,
i.e., consistent results are found
– In different populations,
– In different circumstances, and
– With different study designs.

33
 Consistency
• Smoking and lung cancer
> 100 studies over last 30 years demonstrate increased
risk
• Lack of consistency does not rule out causality
blood transfusion not always a risk for HIV: virus must be
present
• Consistency may only be apparent when all
relevant details of cause are understood

34
 Specificity
One cause leads to one effect, not multiple
effects.

• Main argument of those seeking to exonerate smoking

as cause of lung cancer
• Specificity strengthens evidence for causality, but lack of
specificity does not rule out causality

35
 Temporality
Exposure must precede disease.

• Only criterion which is fundamental to postulating cause

and effect relationship

36
Does the cock crowing make the sun rise?

thanks to
Tom Grein

37
 cont..
• Strong temporality observed in some cases
• Does this mean causation?

• Need more than temporality ……

38
 Biological gradient (dose response)
 Risk of outcome increases with increasing
exposure to the suspected risk factor
Changes in exposure are related to a trend in
relative risk

• linear relationship supports causality: more cigarettes

smoked, greater the risk of lung cancer

39
 Biological Gradient..
Linear relationship not always causal: Downs
syndrome and birth rank

Standardized Mortality Ratios (lung Cancer)

Dose (cigs/day) Study 1Study 2 Study 3
<10 1.3 1.8 1.4
10-20 2.8 2.3 2.4
>40 4.7 3.7 6.3

40
 Plausibility and coherence
Consistency with current biological
knowledge about the disease.

Interpretation of cause-effect relationship does not

conflict with what is known of the natural history
and biology of disease.

Absence of coherence and plausibility cannot be taken as evidence

against causality

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 Experimental evidence
• human experiments
• animal experiments
• does removing exposure
lead to fall in outcome?

42
 Analogy
Existence of other cause-effect relationships
analogous to the one studied supports a causal
interpretation.

• If particular drug is a potent carcinogen, then different

drugs of same class may also be carcinogens
• Weak criterion for causality. Useful for speculating
how risk factor may operate in different context

43
 Summary of Bradford-Hill criteria

• “None of my nine viewpoints can bring

indisputable evidence for or against the cause-
and effect hypothesis ...”.

44
 Causal Inference: Cautions
• No single study is sufficient for causal inference
• Causal inference is not a simple process
– Consider “weight of evidence”, using Bradford Hill’s
criteria
– Always requires judgment and interpretation, no
cookbook method
– Some consider causal inference to be in the public policy
domain, rather than the scientific domain
• No way to prove causal associations
 

45
 Key points

• epidemiologists can never prove a causal relationship

between exposure and disease.

• but they can develop and test hypotheses to establish

causal relationship beyond reasonable doubt
smoking and lung cancer
soya beans and asthma

46
 Chapter two

– Natural History of a disease

47
 2. Natural history of a disease
• The progression of a disease process in an
individual over time, in the absence of
intervention.

• It helps to understand and plan intervention

measures including prevention and control of
diseases.
• Natural history of a disease begins by exposure
to a causative agent capable of causing a disease.
48
• With out intervention, the process ends with
– Recovery
– Disability
– Death

• The course of a disease can be halted by

intervention, any time.

• Eventually the host becomes non infectious by

– Clearing the infection, possibly by developing immunity
– Therapeutic intervention
– Death 49
 2.1. Stages of natural history of
disease
• Four stages
– Stages of susceptibility
– Stages of pre-symptomatic (sub-clinical) disease
– Stage of clinical disease
– Stage of disability or death

• Disability: is limitation of a person’s activities

including his/her role as a parent, wage earner
etc
50
 Natural History of Disease

Pathological Usual Time

Changes Onset of of Diagnosis
Exposure Symptoms

Stage of Stage of
Stage of Stage of Recovery,
Subclinical Clinical Disease
susceptibility Disability, or Death
Disease
Differ
•Duration
Outcome •Severity
Recovery •Outcome
Clinical
51
 Rabies in Humans
First Death occurs
First Onset
Exposure neurological or recovery
Symptom Coma
signs begins
Acute
Incubation Neurological
Period Prodome phase Coma Recovery

20 -60 days 2 -10 days 2-10 days 0 -14days Death

52
 2.2. Chain of Infection
• Infection: implies that the agent has
achieved entry and begun to multiply in the
host and leads to disease.

• This is sometimes called the chain of infection,

or transmission cycle.

• For infection to occur a chain of events must

take place.
53
Chain model of infectious diseases

Causative
agent
Reservoir
Susceptible
host
Portal of
exit
Portal of
entry Mode of
transmission

54
 a. Agent
• Host agent interaction (outcome) is characterized
by
– infectivity, the ability of a pathogen to establish an
infection
– Pathogenicity, is the ability of a pathogen to produce
an infectious disease in an organism.
– immunogenicity, is the ability of a particular substance, such
as an antigen or epitope, to provoke an immune response in the
body of a human or animal.
– Virulence: the proportion of clinical cases resulting in severe
clinical disease (disability, fatality)
– These depends on environmental condition, route of
infection, infective dose, host factor (age, sex, nutritional status)
55
 b. reservoir
• Reservoir: The habitat of an infectious agent
where it normally lives, grows and multiplies
(can be animal, environment, People)
– Eg dog for rabies, - Cattle for anthrax

• Carrier: A person without apparent disease

who is capable of transmitting the agent to
others.
– Asymptomatic carrier: transmitting infection without
ever showing signs of the disease.
56
 Cont…
• Incubatory carrier: transmitting infection by
shedding the agent before the onset of clinical
manifestations.

• Convalescent carrier: Transmitting infection

after the time of recovery from the disease

• Chronic carrier: Shed the agent for a long

period of time, or even indefinitely.
57
 C) Portal of exit
• is the way the infectious agent leaves the
reservoir.

• Possible portals of exit include all body secretions

and discharges:
– Mucus, saliva, tears, breast milk, vaginal and cervical
discharges,
– excretions (feces and urine), blood, and tissues
(including the placenta).
58
 d. Portal of entry
 Is the site where an infectious agent enters a
susceptible host. These are:
The Mucosa:
• Nasal - common cold
• Conjunctiva - Trachoma
• Respiratory - Tuberculosis
• Vaginal - Sexually transmitted diseases
• Urethral - Chlamydial infection
• Anal - Sexually transmitted diseases
Injury site: Tetanus
Skin: Hook worm infection (Ancylostomiasis)

59
 e. Susceptible human host
• The susceptible human host is the final link in
the infectious process.
• Host susceptibility or resistance can be seen at
the individual and at the community level.
• Host resistance at the community (population)
level is called herd immunity.

60
 Susceptible host…

• Herd immunity can be defined as

– the resistance of a population to the introduction
and spread of an infectious agent,
– based on the immunity of a high proportion of
individual members of the population,
– thereby lessening the likelihood of a person with a
disease coming into contact with susceptible.

61
 Herd immunity….
• Example - If 90 % of the children are
vaccinated for measles, the remaining 10 % of
the children who are not vaccinated might not
become infected with measles because most
of the children (90 %) are vaccinated.
• That means transmission from infected person
to other susceptible children will not be
easier.

62
 Herd immunity cont…
Conditions under which herd immunity best functions
1)Single reservoir (the human host): If there is other
source of infection it can transmit the infection to
susceptible hosts.
2)Direct transmission (direct contact or direct
projection): Herd immunity is less effective for diseases
with efficient airborne transmission.
3)Total immunity: Partially immune hosts may continue
to shed the agent, and hence increase the likelihood of
bringing the infection to susceptible hosts.
 Herd immunity cont…
4) No shedding of agents by immune hosts (no carrier
state).
5) Uniform distribution of immunes: Unfortunately,
susceptibles usually happen to live in clusters or
pockets because of socioeconomic, religious, or
geographic factors.
6) No overcrowding: Overcrowding also increases the
likelihood of contact between reservoirs and
susceptible hosts.
•  However, these conditions for the operation of
herd immunity are seldom fulfilled.
 2.3. Time course of an infectious
disease
• Pre-patent Period: The time interval between
biological onset and the time of first shedding of the
agent.
• Incubation Period: Interval between infection
( biological onset) and the first clinical
manifestations of disease (clinical onset).
• Communicable Period: The time interval during
which the agent is shed by the host.
• Latent Period: The interval between recovery and
the occurrence of relapse or recrudescence in
clinical disease.

65
Generation time
• With person-to-person spread, the interval between cases
is determined by the generation time
• It is the time between the receipt of infection by a host
and maximal communicability of that host.

-Examples of diseases in which a latent period can occur

include malaria and epidemic typhus.

66
 Fig 9. Time course of a disease in relation to
its clinical expression and communicability
Clinical case
Symptomatic

Co
Clinical

nv
Threshold

ale
er

sc
r ri

en
ca

Asymptomatic carrier Chronic carrier

tc
Asymptomatic
y

ar
r
to

rie
a
ub

r
c
In

TIME
Time of infection Agent starts 1 manifestation of Recovery Agent stops Relaps
st

(biological onset) being shed disease (clinical being shed e

onset)
Latent
Incubation period period
Prepatent
period
Communication
period 67
Generation
 2.4. Modes of Transmission
• The transfer of an infectious agent from an infected
host (reservoir) to a susceptible host

• Direct transmission: Immediate transfer of the

agent from a reservoir to a susceptible host.

• Indirect transmission: Transmission of an

infectious agent to a susceptible host through the aid
of a vehicle, a vector or suspended air particles.

68
 Mode of Transmission…..
• Is the various mechanisms by which agents are conveyed
to a susceptible host.
1. Direct transmission
1.1 Direct contact: The contact of skin, mucosa, or conjunctiva
with infectious agents directly from person or vertebrate
animal, via touching, kissing, biting, passage through the
birth canal, or during sexual intercourse.
Example: HIV, rabies, gonorrhea
1.2 Direct projection: projection of saliva droplets by coughing,
sneezing, singing, spitting or talking.
Example: common cold
1.3Transplacental: Transmission from mother to fetus.
Example: syphilis
69
 Mode of Transmission cont…
2. Indirect transmission
2.1 Vehicle-borne:
• A vehicle is any non-living substance or object by
which an infectious agent can be transported and
introduced in to a host through a suitable portal
of entry.
• Transmission occurs through indirect contact
with inanimate objects (fomites): bedding, toys,
or surgical instruments; as well as through
contaminated food, water, IV fluids etc.
70
 Mode of Transmission cont…
2.2 Vector-borne:
A vector is an organism (usually an arthropod)
which transports an infectious agent to a
susceptible host or to a suitable vehicle.
 Biological vector:
• A period of multiplication and/or development of the
agent in the vector is required before transmission
to the host can occur (extrinsic incubation period).
• Transmission occurs while the vector is feeding on its
host.
71
 Mode of Transmission cont…
• two ways of transmission by biological vector: salivarian and
stercorarian
– Salivarian - Infective saliva is directly injected in to the
host.
Example: Malaria by the anopheles mosquito
– Stercorarian- Infective fecal or regurgitated material is
deposited near the bite wound .
-The host then auto-inoculates the infective material by
scratching the itching bite. Example: flea borne or louse
borne typhus.
-Alternatively, infective material from a crushed louse can be
rubbed into the bite wound or into a skin abrasion
72
 Mode of Transmission cont…
Mechanical vector:
– agent is directly infective to the host, without having to go
through a period of multiplication or development.
– agent is transported (carried) on the leg or mouth parts of
the vector,
– or passes through its gastrointestinal tract and is excreted
or regurgitated onto the host or vehicle.
– Introduction of the agent into the host is either:
– by bite (e.g rift valley fever by blood sucking flies),
– by vector-host contact (e.g- Trachoma by flies), or
– through contamination of a vehicle (e.g contamination
of food by flies or cockroaches).
73
 Mode of Transmission cont…
2.3 Airborne: which may occur by dust or
droplet nuclei (dried residue of aerosols)
Example: Tuberculosis
2.4 Non vector intermediate host: hosts not
playing an active role in transporting the
agent to humans.
Example: Aquatic snails in the transmission of
schistosomiasis.

74
 Cont…
• Direct transmission • Indirect transmission
 Touching  Airborne

 Kissing
 Vehicle-borne
 Biting
 Vector-borne
 Direct projection
 Non-vector
 Blood transfusion
intermediate host

 Parenteral injections
75
2.5. Levels of Disease Prevention

• It is important for implementing interventions that

prevent infections or ameliorate infections.

• Involves the interruption or slowing of disease

progression through appropriate intervention.

• Epidemiology plays a central role in disease prevention

by identifying modifiable causes of disease and their
risk factors

76
 Cont….
There are several stages during the course of a disease
at which we can intervene in order to control the
disease.

Three levels, (Primary, Secondary and Tertiary)

I. Primary prevention
 The objectives here are to promote health,
prevent exposure, and prevent disease.
 The aim is preventing health people from becoming
sick
77
 Cont…
A. Health promotion (Primordial):
• This consists of general non-specific interventions
that enhance health and the body’s ability to resist
disease – including:

• The improvement of socioeconomic status through

the provision of adequately.
– paid jobs,
– education,
– affordable and adequate housing and clothing, etc.

78
 Cont…
B. Prevention of exposure:

• There are many examples of interventions aimed at

this stage,

• Relatively to specific compared to primordial

prevention
– the provision of safe and adequate water, of
proper excreta disposal,
– Provision of vector control;

– Provision of a safe environment at home

79
 Cont…
C. Prevention of disease:
• Timing is between exposure and biological onset.

– Immunization
• Active (antigens)
• passive (ready made antibody, commonly
after exposure)
• Both types of immunization are after
exposure has taken place.

80
– Some times it may be difficult to differentiate
interventions in what form of prevention they
involved

– Breastfeeding is an example of an intervention

which acts at all three levels of primary
prevention.

81
 Cont…
II. Secondary prevention
– Interventions that act after the biological onset of
disease, but before permanent damage sets in.

– The objective here is to stop or slow the

progression of disease so as to prevent or limit
permanent damage.

– Strategy at this stage is through early detection

and treatment of disease.

82
 Cont…
III. Tertiary prevention
• Intervention that acts after permanent damage has
set in, and
• The objective of tertiary prevention is to
– Treatment to prevent further disability or death
– limit the impact of that damage.
• The impact can be physical, psychological, social
(social stigma or avoidance by others), and
financial.
• Strategy at this stage in general is rehabilitative.
• Rehabilitation is the retaining of the remaining
functions for maximum effectiveness.
83
2.6. Levels of Disease Occurrence

84
 Levels of Disease

Increasing amount of disease

Pandemic

Epidemic

Endemic

Sporadic
85
Levels of Disease Occurrence…
Diseases occur in a community
1. by difference in level of disease at a point in time

2. Excess or predictable levels of what is expected

1. Level of occurrence of disease

Endemic: the usual presence of disease from low to
moderate level

Hypo/Hyper-endemic: a persistently lower or high

level of disease

Sporadic: Normally does not occur, but occasional cases

occur at irregular intervals
86
 Cont….
2. Excess of expected levels
Epidemic: An excess occurrence of disease over
expected level at certain time.

Outbreak: Synonymous with epidemic, but

characterized by a sharp rise and fall in incidence,
(usually to occurrence in a limited area.

Pandemic: An epidemic that affects several

countries or continents. (eg HIV/AIDS)

87
 2.7. Disease Classification

1. Time Course 2. Cause

– Acute: rapid onset and – Infectious
short duration
– Non-infectious
– Chronic: characterized
by prolonged duration

– A chronic disease can have

both acute and chronic
manifestations

88
2.8. Infection and Disease Outcome

• Exposure to an infectious agent does not

necessarily lead to infection, and

• An infection does not necessarily lead to

disease

• Infection may remain asymptomatic or sub-

clinical, or may lead to overt clinical disease
89
 Cont…

Disease
Exposure Infection Disease
outcome

Infectiousness Pathogenicity Virulence

Fig 10. Outcomes at each stage of infection

90
 Cont…
• The progress of an infectious agent and disease
outcome can be quantified as follows:

1. From exposure to infection

 Infectiousness: the proportion of an exposed
susceptible host who become infected (measured by
infection rate), as:

No. infected X 100

No. susceptible and exposed

91
 Cont…
2. From infection to disease

 Pathogenicity: the proportion of infected

people who develop clinical disease, and
measured by the clinical-to sub-clinical ratio, as:

No. of clinical cases X 100

No. of sub-clinical cases

92
 Cont….
3. From disease to disease outcome

 Virulence: the proportion of persons with clinical

disease who become severely ill or die, and
measured by Case-fatality-rate and hospitalization
rate

No of death of a specific disease

Case-fatality-rate = Total No of cases of that specific disease X 100

No of hospitalized persons of a specific diseaseX 100

Hospitalization rate =
Total No of cases
93 of that specific disease
2.9. Variation in Severity of Illness

• Infectious disease has a wide spectrum

of clinical effects.

Mild Severe
In apparent Death
disease Disease
infection
No signs
Clinical illness with symptoms
or
symptoms

The spectrum of disease from communicable disease

94
• Spectrum of illness
In apparent Death
Mild disease Sever disease
infection

or Recovery
No sine or
inapparent infection
symptom

• Severity of an illness
In apparent
Mild Moderate Severe Fatal
Likely to be seen by doctor, but not usually
recorded
Likely to be hospitalized and
recorded which tells us case
severity
95
 Important Terms in Infectious
Disease Epidemiology
• Incidence: It refers to the number of new cases
in a given time period
• Prevalence: It refers to the number of cases at a
given time expressed as a percent at a given.
• Case Fatality: It refers to the proportion of
infected individuals who die of the infection.

96
• Factors Affecting Infectivity of an Infectious
Disease/Agent
– Dose and route

– Strain of the agent

– Immunity of host

– Nutritional status of host

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 Epidemiology of Vaccination

• Immunization could be a direct one or an indirect

one.
– Direct: This is immunity gained after infection or by
vaccination/immunization
– Indirect: This is acquired because of herd immunity

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• Vaccine efficacy is assessed by comparing
incidence of a particular disease among
vaccinated and unvaccinated people.
• Vaccine Efficacy (%) = (Iu-Iv)/Iu X 100%

• Where,
– Iu – Disease incidence in the unvaccinated
– Iv – Disease incidence in the vaccinated

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 Types of immunity
A. Natural
– (i) Active: Infection by an agent stimulates the host to
produce antibodies
– (ii) Passive: Antibodies produced by the mother cross the
placenta into the blood stream of the fetus i.e. maternal
antibodies
B. Artificial
– (1) Active: Host is stimulated to produce antibodies by the
injection of an attenuated pathogen (an antigen)
• i) Killed vaccine
• ii) Modified live vaccine
– (2) Passive: Host receives antibodies produced elsewhere
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 Some Basic Concepts

• Health is a difficult concept to define.

• What is health?

• WHO in 1947 defined health as “A state of

complete physical, mental and social well being and
not merely the absence of disease or infirmity.”

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 Clinical Versus Community
Medicine
• Clinical medicine is concerned with
– Diagnosing and treating diseases
– In individual patients,
• While
• Community medicine is concerned with
diagnosing the health problems of a community,
and with planning and managing community
health services.
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• Public health
– a science, an art and a profession of
• preventing disease,
• prolonging life, and
• promoting health and efficiency through organized
community effort (for sanitation, control of
communicable disease, health education, etc.)

• Information on the health and disease of a

defined community is gathered through
Community Diagnosis.
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• Community Diagnosis
– the process of identification and detailed description
of the most important health problems of a given
community
• Methods of Community Diagnosis:
– Discussion with community leaders and health
workers
– Survey of available health records
– Field survey.
– Compilation and analysis of the data.
• Then prioritization
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• It is impossible to address all the identified problems at
the same time because of resource scarcity. Therefore
the problems should be put in the order of priority using

a set criterion.
• Criteria for priority setting
– Magnitude: (amount or frequency) of the problem
– Severity: (to what extent is the problem disabling, fatal)
– Feasibility: (availability of financial and material resource,
effective control method and acceptance by the community)
– Community concern: (whether it is a felt problem of the
community)
– Government concern: (policy support, political commitment)
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 Disease, Illness and Sickness
• Disease is literally the opposite of ease. It is
physiological or psychological dysfunction.

• ILLNESS is the subjective state of a person who

feels aware of not being well

• Sickness is a state of social dysfunction; i.e. a role

that an individual assumes when ill.
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• How do you measure disease frequency?
• What are measurements of morbidity?

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• Thank you!!!

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