CONCEPT OF DISEASE IN EPIDEMIOLOGY

DEPARTMENT OF EPIDEMIOLOGY AND BIOSTATISTICS

Dengue infection
Public Health problem in Tropics & Sub-tropics Guiness World Records 2002 : most important viral hemorrhagic fever & most geographically wide-spread of Arbovirus diseases Dengue shock syndrome : causes a significant number of childhood deaths

Mortality rate of Dengue Hemorrhagic Fever Indonesia - 1968 : 41,3 % - 1984 : 3,0 % - 1998 : 1,9 % - 2003 : + 2,0 % Queen Sirikit National Institute of Child Health (Children Hospital) Bangkok : - 1970 : 10 % - 1984 : 2 % - 1990 : 0.2 % Target of WHO : < 1 %

IS IT A PROBLEM
FOR US ?

TO ANSWER THE PROBLEM IN MANAGING DENGUE HEMORRHAGIC FEVER OUTBREAK

1. PROMPT TREATMENT

2. DEFINE FACTORS THAT INFLUENCE

THE OCCURRENCE OF THE DISEASE 3. PREVENTION

OBJECTIVE

TO DEFINE A CAUSE OF DISEASE AS A FACTOR (CHARACTERISTICS, BEHAVIOR, EVENT) THAT INFLUENCES THE OCCURRENCE OF DISEASE

FACTORS IN DISEASE CAUSATION

1. Predisposing factors age, sex and previous illness 2. Enabling factors low income, poor nutrition, bad housing, inadequate medical care 3. Precipitating factors exposure to a specific disease agent or noxious agent 4. Reinforcing factors repeated exposure, unduly hard work

THE EPIDEMIOLOGIC TRIANGLE

"triad" that play a role in disease process
Agent

Vector Host Environment

TRADITIONAL MODEL OF INFECTIOUS DISEASE CAUSATION

AGENT

As an element or substance, animate or inanimate, the presence (or absence) of it may initiate or perpetuate a disease process

HOST
A person or other living animal, that affords subsistence or lodgment to an infectious agent under natural condition

Host factors Intrinsic factors that influence an individuals exposure, susceptibility, or response to a causative agent

ENVIRONMENT

As the aggregate of all the external conditions and influence affecting the life and development of an organism

Environmental factor Extrinsic factors which affect the agent and the opportunity for exposure

AGENT
a. Nutritional agent
carbohydrate, vitamin, fat, protein, mineral, water Example : - diabetes mellitus, obesitas, hyperlipidemia, kwashiorkor - avitaminosis - cretinism, anemia - edema, dehydration

b. Chemical agent
polutan , drugs, Hg, Pb, Ag, arsenicum, pesticide (Chlorinated Hydrocarbon CCl4 : DDT, endrin, dieldrin and organo hosphate, diacynon, malathion, butazinon), cosmetics, etc. c. Physical agent collision, traffic accident, falling down, dust, climate (frost bite, heat stroke)

d. Infectious agent - Virus : dengue, morbili, varicella, hepatitis - Ricketsia : typhus exanthematicus, Rocky Mountain Spotted Fever, scrub typhus (rat-bite fever) - Bacteria : gram (+), gram (-) ; bacil, coccus, acid fast resistence, anaerob, etc. - Fungi : tinea capitis, tinea cruris, tinea pedis - Protozoa : plasmodium, amoeba - Metazoa : worm (ascaris , ancylostoma, etc.)

HOST
Intrinsic factors that play a role in disease process - age - sex - religion - customs - occupation - marital status - family background - genetic-hereditary - ethnic / race - physiologic / psychological status - habit / behavior - immune status - previous disease

ENVIRONMENT
1. Physical environment geographic, geology, climate

2. Biological environment people, flora, fauna, food population density

3. Socioeconomic
income, education, culture, urbanization, economic growth, poverty, fertility, etc.

NATURAL HISTORY AND SPECTRUM OF DISEASE

Natural history of disease

The progress of a disease process in an individual overtime in the absence of intervention

recovery Exposure host disease disability death

INCUBATION PERIOD

The time interval between contact with an agent and the first clinical evidence of resulting disease Depends on : Portal of entry (defense mechanism) The ability of multiplication (infectivity) Number of agents Level of antibody in the host It varies individually

Type of incubation period in disease outbreak

number of cases

B
time

A : skewed to the left the disease has a short incubation period B : skewed to the right the disease has a longer incubation period

DEFENCE MECHANISM

THE ABILITY TO REACT AGAINST AGENT INVASION IN THE BODY

Consist of :

The external defense mechanism : physical and chemical reaction

The internal defense mechanism : cellular and humoral immunity

EXTERNAL BARRIER Respiratory tract sense of smell, cough and sneeze reflex, mucous membrane, hair of the nose, ciliated epithelium. Small particles < 5 can enter directly into the alveoli. Digestive tract sense of taste, vomit reflex, gastric acid fluid, peristaltic of intestine and diarrhea Skin structure of the skin, sebaceous glands, apocrine and accrine sweat glands, hair Eye blink reflex, eye brow, eye lash, tears

If the external barrier can not eliminate the agent

internal defense mechanism will continue the defence mechanism process by : - Inflammation

- Isolation by fibrocyte
- Macrophage phagocytosis

- Antibody reaction
Immunization a way to increase the internal defence mechanism

The natural history and spectrum of disease

challenges to the clinician and to the public health worker

To the clinician Because of cases diagnosed by clinicians in the community often represent only the tip of the iceberg, it is important to do the case finding and report it to the public health worker

To the public health worker

While searching the rest of the cases, they should prevent disease transmission and outbreak

ICEBERG PHENOMENE
CLINIC

CLINICAL HORIZON

SUB CLINIC

CURE

The proportion of sub clinical patients are greater in number than the patients with complete symptoms This portion should be early detected, because it has the capability of transmitting the disease causing outbreak

CELL RESPONSE Lysis of cell Discernable effect Inclusion body formation or cell transformation or cell dysfunction

HOST RESPONSE Death of organism Clinical disease Classical and severe disease

Moderate severity mild illness

Viral multiplication without visible change or Below visual change incomplete viral maturation

Infection without clinical illness (asymptomatic infection) Subclinical disease

Exposure without attachment and/or cell entry

Exposure without infection

CHAIN OF INFECTION

AGENT CHARACTERISTIC 1. Natural characteristics of the agent The morphology, physiology, reproduction, motility, metabolism, need of oxygen , temperature, production of toxin, antigen, living cycle, reaction against physical and chemical substance 2. Characteristic of the agent related to infection in human a. infectivity b. pathogenicity

c. virulence
d. antigenicity e. tropism

3. Reservoir of agent 4. Portal of entry and portal of exit

5. The incubation period

6. The spread of the disease

7. Natural cycle of infection

INFECTIVITY The ability of agent to attack, adapt, live and multiplicate in the host

PATHOGENICITY The ability of agent to produce a local or general reaction in the host

VIRULENCE The ability to elicit a severe clinical manifestation

ANTIGENICITY

The agents ability to stimulate host production of antibody such as agglutinin, opsonin, precipitin, antitoxin, lysine, complement fixating substance,etc.

Disease with high antigenicity can be prevented by immunization

Example :
Typhoid fever, morbili Tuberculosis : highly antigenic : doubtful

Influenza virus has lots of strain :

rather difficult to develop an effective vaccine

Agent with high infectivity and pathogenicity but low antigenicity will cause a relatively high disease prevalence in the community

Agent with high infectivity but low pathogenicity usually produce a mild or sub clinical symptom and carrier TROPISM The agent preference to attack and stay in special location in the host Cholera : digestive tract Staphylococcus : mostly in the skin Herpes zoster : nerve system Poliomyelitis : anterior-horn cells of spinal cord

HERD IMMUNITY The immunity of a group of people / community.

The resistance of a group to invasion and spreading of an infectious agent group. The herd immunity reduces the susceptibility to infection or based on the resistance to infection of a high proportion of individual members of the

can resist a communicable disease epidemic.

The higher herd immunity the higher the power to

defence of an epidemic occurrence.

The high incidence of communicable disease

can be due to : the high proportion of the susceptible individual or the low portion of herd immunity in the population

The practical aspect of the concept of herd immunity : the necessity of immunization program for the whole population to prevent the occurrence of an epidemic

RESERVOIR Habitat in which an infectious agent normally lives, grows and multiplies

1. HUMAN RESERVOIR 2. ANIMAL RESERVOIR 3. ENVIRONMENTAL RESERVOIR

1. Human reservoir
- Persons with symptomatic illness - Carrier

Carrier : a person without apparent disease who is nonetheless capable of transmitting the agent to others a. Asymptomatic carrier
(never show symptoms during the time they are infected)

b. Incubatory / convalescent carrier

(who are capable of transmission before or after they are clinically ill)

c. Chronic carrier
(who continues to harbor an agent)

2. Animal reservoir
Infectious disease that are transmissible under normal conditions from animals to human are called zoonoses Dog, cat, ape : rabies Rat : rat bite fever, plaque, leptospirosis Cattle : sheep, goat, camel, cow, pig (anthrax, brucellosis, bovine tuberculosis, tularemia, ring worm) Arthropode : flies, cockroach, mosquito

3. Environmental reservoir (soil)

Clostridia (tetanus, botulism, welchii)

Fungi
Bacteria (dust particle : mycobacterium tuberculosis)

Parasite (helminthiasis)

PORTAL OF ENTRY AND PORTAL OF EXIT

The path by which an agent enters of leaves the source host.

Usually corresponds to the site at which the agent is localized. It is necessary to understand about it because it related to how the disease being transmitted in other way we can assume how the prevention of the disease.

Portal of entry - digestive tract - respiratory tract - skin - genital - eye - blood vessel system The portal exit seem to be the same with the portal entry, sometimes some disease have other way of exit beside the former way.

Hepatitis infectiosa, typhus abdominalis : beside come out by fecal also can be detected in urine and blood.

TRANSMISSION

4 transmission ways :

1. Contact transmission
a. Direct transmission : by mucous contact e.g. genital-genital, oral-genital, oral-oral

b. Indirect : hand-mouth, droplet transmission

2. Vehicle transmission - Transmission by common vehicle : food, fluid, milk, blood, serum, vaccine - The agent can be transmitted by ingestion, injection or inoculation 3. Vector transmission The arthropods have a role in this transmission 4. Air borne - droplet nuclei - dust

Transmission of Dengue Virus by Aedes aegypti

Mosquito feeds / acquires virus Extrinsic incubation period

Mosquito refeeds / transmits virus

Intrinsic incubation period

Viremia
0 5 8 12 16 20

Viremia
24 28

Illness Human #1

DAYS
Human #2

Illness

Replication and transmission of Dengue virus (part 1)

1. Virus transmitted to human in mosquito saliva 2. Virus replicates in target organs 3. Virus infects white blood cells and lymphatic tissues 4. Virus released and circulates in blood

2 4 3

Replication and transmission of Dengue virus (part 2)

5. Second mosquito ingests virus with blood 6. Virus replicates in mosquito midgut and other organs, infects salivary glands 7. Virus replicates in salivary glands

Theoretically, the spreading of the disease can be stopped by cutting off every step of the disease phase. The principle of communicable disease control is to cut off the chain of transmission of the disease. Example : 1. To cut the connection between the reservoir and the host (contact person) by : individual hygiene environmental sanitation 2. To increase the defense mechanism by : immunization nutrition 3. In case the colonization has been occurred : early diagnosis & prompt treatment screening : malaria, STD, HIV-AIDS

IMPLICATION
FOR PUBLIC HEALTH

By knowing how an agent exits and enters a host, and what its modes of transmission are, we can determine appropriate control measures, including prevention methods

FOR CLINICAL/HOSPITAL SETTING

Patients may be treated and/or isolated with appropriate precautions

NATURAL HISTORY OF ANY DISEASE

PREPATHOGENIC PATHOGENIC

D E A T H
CLINICAL 1 Agent Host Clinical Horizon Environment 2 3

interaction

Sub Clinic

Convalescence

Cured + Sequel

PRIMARY PREVENTION I

SECONDARYP REVENTION II

TERTIARY PREVENTION III

STAGE OF PREVENTION

I. PRIMARY PREVENTION
Health promotion and specific protection A. Health Promotion 1. Health education

2. Nutrition
3. Development 4. Housing

5. Marriage counseling
6. Genetic 7. Periodic physical examination

B. Specific protection
1. Immunization 2. Personal hygiene 3. Environmental sanitation 4. Occupational hazard

5. Protection to accident
6. Specific nutrition 7. Protection to carcinogen 8. Avoidance of allergic material

II. SECONDARY PREVENTION Early diagnosis and prompt treatment

1. Case finding 2. Screening survey

3. Selective examination
a. Cure and prevent b. Preventing the spread

c. Preventing complication and sequel

d. Shorten of disability

III. TERTIARY PREVENTION

Disability limitation and rehabilitation 1. Disability limitation a. Addition of training b. Provision of facility

2. Rehabilitation a. Provision of facility b. Education c. Full employment d. Selective places e. Work therapy f. Sheltered colony