RISK TRANSITION/

EPIDEMIOLOGICAL TRANSITION

Any major shift in patterns of

disease or causes of death that
affects the level and character of
mortality in a population

DR UMER FAROOQ
MSPH SECOND SEMESTER
ALSHIFA SCHOOL OF PUBLIC HEALTH
 First Epidemiological Transition
TheFirst Epidemiological
Transitionoccurred100 centuries agowhen
manmovedtowardstheagricultural society.
Byeschewingthenomadiclifestyle,people
stayedinoneplaceandincreasedtheir
contactwithhuman(andanimal)waste,and
contaminatedtheirwatersupplies.
Andeventhecultivationofsoil,andthe
clearingofland,exposedpeopletoinsect
bites,bacteria,andparasites.
Ascitiesgrew,andexplorationofthe
surroundingworldincreased,man spread
deadly diseasesinever-greaternumbers.
 First Epidemiological Transition..
Thisepidemiologicaltransitionwasdescribedas

the age pestilence and famine".
Epidemic, famines and wars caused huge
numbersofdeaths.
Infectiousdiseasesweredominant,causinghigh
mortalityrates,especiallyamongchildren.
Thedomesticationofanimalsbroughtother
diseasevectorsinclosecontactwithhumans.
QFever,Anthrax,tuberculosisgainedaccess
tohumanhosts.
Whileincreasingfoodsecurityandnutrition,this
transitionalsointroducedseveralsignificant
First Epidemiological Transition..
Inthisstage,womenof
childbearingagealso
facedconsiderablerisks
duetothecomplications
associatedwith
pregnancyandchildbirth.
Somedeveloping
countriesarestillinthis
stage.
Second Epidemiological Transition
TheSecondEpidemiological
Transitionbeganroughly200
yearsago,withtheIndustrial
revolution.
Whilemanyoftheexisting
diseasesbroughtforthduring
thefirsttransitioncertainlydid
notgoaway,new-chronic, non-
infectious, degenerative
diseaseswereaddedtothe
mix.
Second Epidemiological Transition

Thisphasewasdescribedas
age of receding pandemics
Itinvolveda reduction in the prevalence of infectious
diseases, and a fall in mortality rates.
CDR reaches a level of less than 30 deaths per 1,000
population.
IMR was150 per 1,000 live births.
As a consequence, life expectancy at birth climbed
rapidlyfromabout35to50years.
Second Epidemiological Transition
Increased economic growth led to a
sharp fall in deaths from infectious
diseases,andfrommalnutrition.
This Improvement occurred before
effectivemedicaltreatmentandwasdue
toimpactoffollowinginterventions:
clean water
sanitary sewage
mosquito suppression (malaria/yellow
fever)
increased food safety refrigeration and
pasteurization
increased pre & post-natal care
Second Epidemiological Transition

Finally,theintroductionofmodern healthcare and health

technologies, e.g.
immunization programs
introduction of antibiotics

enabledthecontrolandeliminationofgroupofinfectiousdiseases
suchasDiphtheria, polio and smallpox.
Second Epidemiological Transition
Technologyalsobroughtwithit
smokestackindustries,chemical
toxins,workingindoors,stress,
greateraccesstoless`healthful
food;besideadvancesinmedicine
andsanitation.
Andwiththissecondtransitionweve
seenrisesinallergies,asthma,
autoimmunedisorders,andsexually
transmitteddiseasesaswell.
Second Epidemiological Transition

As fertility rates were high, population was growing

rapidly at this stage of the health transition. Without
moving to the next stage, the carrying capacity of the
localecosystemmaybeexceeded.
As population and ecological pressures increased, food
and water became scarcer, and the lack of ecological
and social resourcesmaycauseeconomicdevelopment
tostagnate.
If there is a surplus of available resources, the
transitionmaybeaccelerated,butiftheyarelacking,the
transitionmayslow,orevenstagnateinthisphase.
Third Epidemiological Transition
Beganinthelate20thcentury.
Thisphasewasdescribedas
The age of chronic diseases

Inthethirdstagetheeliminationof
infectiousdiseasesmakeswayfor
chronicdiseasesamongtheelderly.
Themajorcausesofdeathareso-
calledchronicdegenerativeandman-
madediseasessuchas
cardiovasculardiseases,cancer,and
diabetes.
Third Epidemiological Transition
While improved healthcare means
that these are less lethal than
infectious diseases, they
nonetheless cause relatively high
levels of morbidity.

Increasingly,healthpatternsdepend
on social and cultural behaviour,
such as patterns of food
consumptionanddrinkingbehaviour.
Hybristic Stage

RogersandHackenberg(1987)feltthattheoriginaltheory
lackedreferenceto violent and accidental deathsand
deathsduetobehaviouralcauses.
Theyproposed a fourth stage thattheycalledthe
hybristicstage.
Thetermhybrisreferstoexcessiveself-confidenceor
abeliefofinvincibility.
Duringthehybristicstage,morbidityandmortalityare
affectedbyman-madediseases,individualbehaviours,and
potentiallydestructivelifestyles.
Hybristic Stage

RogersandHackenberg(1987)furtherremarkedthatwhile
mostenvironmentally-basedinfectiousdiseasesare
eradicatedduringthehybristicstage,someinfectious
diseasesareincreasinginimportanceduetoindividual
lifestylesandman-madecauses.

Awell-knownexampleofsuchaninfectiousdiseaseis
HIV/AIDS.
Future stages of the epidemiological transition

Martens(2002)describedthedevelopmentsinthehealth
status of populations according to three potential future
'ages:

4. the age of emerging infectious diseases

5. the age of medical technology
6. the age of sustained health

Thesestagesareimaginary(althoughsomefeaturesare
already recognizable in some countries) and are not
sharplydelineatedthere is always a continuum.
The age of emerging infectious diseases

Inthisstage,theemergence of new infectious

diseases or the re-emergence of 'old' ones will
have a significant impact on health.
Anumberoffactorswillinfluencethis
development:
travelandtrade
microbiologicalresistance
humanbehaviour
breakdownsinhealthsystems
increasedpressureontheenvironment
The age of emerging infectious diseases

Social,politicalandeconomic
factorsthatcausethe
movementofpeoplewill
increasecontact between
people and microbes.

Environmentalchangescaused
byhumanactivity(forexample,
dam and road building,
deforestation, irrigation, and,
at the global level, climate
change)willallcontributetothe
furtherspreadofdisease.
The age of emerging infectious diseases

Theoveruse of antibiotics and insecticides, combined

with inadequate or deteriorating public health
infrastructures will hamper or delay responses to
increasingdiseasethreats.

As a result, infectious diseases will increase

drastically,andlifeexpectancywillfall.
The age of emerging infectious diseases

Illhealthwilllead to lower levels of economic activity,

and poor countries will be caught in a downward
spiral of depressed incomes and bad health.

Control of infectious diseases will be hampered by

politicalandfinancialobstacles,andbyaninabilitytouse
existingtechnologies.
The age of medical technology

Toalargeextent,increasedhealthriskscausedby
changesinlifestyleandenvironmentalchangeswill be
offset by increased economic growth and technology
improvements in the age of medical technology.

Ifthereisnolongterm,sustainableeconomic
development,increasedenvironmentalpressureand
socialimbalancemaypropelpoorsocietiesintotheageof
emerginginfectiousdiseases.
The age of sustained health

Intheageofsustainedhealth,investments in social
services will lead to a sharp reduction in lifestyle
related diseases,andmostenvironmentallyrelated
infectiousdiseaseswillbeeradicated.

Healthpolicieswillbedesignedtoimprovethehealth
statusofapopulationinsuchawaythatthehealthof
futuregenerationsisnotcompromisedby,forexample,
thedepletionofresourcesneededbyfuturegenerations.
The age of sustained health

Althoughthereisonlyaminimalchancethatinfections
willemerge,improvedworldwidesurveillanceand
monitoringsystemswillmeanthatanyoutbreakis
properlydealtwith.

Despitetheageingoftheworldpopulation,health
systemswillbewelladjustedtoanolderpopulation.

Furthermore,disparitiesinhealthbetweenrichandpoor
countrieswilleventuallydisappear.