By

Dr.N.C.Ashok
Professor and Head
Dept. of Community Medicine
JSS Medical College
Mysore
- Disease results from a complex interaction between
man, an agent and the environment.

Environment

Agent Host

- It is the key concept in epidemiology

- Signifies the way in which a disease evolves over
time from the earliest stage of its pre-pathogenesis
phase to termination as recovery, disability or death
in the absence of treatment or prevention.

-Each disease has its own unique natural history,

which is not necessarily the same in all individuals.
- Natural history of disease is best established by
Cohort studies

-Cohort studies are costly and laborious, thus our

understanding of the natural history of disease is
largely based on other epidemiological studies,
such as cross - sectional & retrospective studies,
undertaken in different population settings, both
national & international.
 -The physician sees an “episode of the natural history
of disease in his hospital.

-While the epidemiologist, by studying the natural history

of disease in the community setting fills the gap in our
knowledge about the natural history of disease.
Schematic diagram of natural history of disease.
-It is customary to describe natural history of the disease in
2 phases.

i. Prepathogenic phase
- i.e. process in the environment

ii. Pathogenic phase

- i.e. process in man
i. Pre-pathogenesis phase:

- The period preliminary to the onset of disease in man

- Disease agent has not yet entered man, but the factors
which favour its interaction with human host are
already existing in the environment.

- Referred as “Man in the midst of disease”

or
“Man exposed to the risk of disease”
-Potentially we are all in the pre-pathogenesis phase of
many diseases, both communicable & non-communicable

- Causative factors of disease classified as -

i. AGENT

ii. HOST and

iii. ENVIRONMENT

These 3 factors are referred to as epidemiological triad

 - An “interaction” of these 3 factors

Initiates the disease process in man

-Agent, Host & Environment operating in combination

determine not only the onset of disease which may range
from a single case to epidemics, but also the distribution
of disease in the community.
 Epidemiologic concept of
Interaction of Agent, Host & Environment
ii. Pathogenesis Phase:

- Begins with the entry of the disease “agent” in the

susceptive human host

- The disease gent multiplies and induces tissue &

physiological changes, the disease progresses through
a period of incubation & later through early & late
pathogenesis
- The final outcome of the disease may be recovery,
disability or death

- Pathogenesis phase may be modified by intervention

measures such as immunization & chemotherapy.
- The Host’s reaction to infection with a disease agent
is not predictable

i.e. the infection may be

a. Clinical or b. Sub - Clinical

Typical or atypical or Host may become

a carrier with or without
having developed
clinical disease as in
the case of diphtheria &
Poliomyelitis
- In chronic diseases (eg: CHD,HTN,Cancer), the early
pathogenesis phase is less dramatic

-This phase of chronic disease is referred to as -

Presymtomatic phase

- i.e. there is no manifestation of the disease.

-The pathological changes are essentially below the level

of the “clinical horizon”
- The clinical stage begins when recognizable signs or
symptoms appear.

- i.e the disease phase is already well advanced into the

late- pathogenesis phase
Agent factors :
- First link in the chain of disease transmission

-Defined as a 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.

- May be a single agent or a complex of two or more

factors whose combined presence is essential for
development of the disease.
 Disease agents may be-

1. Biological agents:
There are living agents of disease like viruses,
Rickettsiae, fungi, bacteria, protozoa & metazoa

-Exhibit certain ‘host-related’ biological properties such

as -
a. Infectivity- The ability of an infectious agent to invade
& multiply in host
b. Pathogenicity
c. Virulence
Pathogenicity – The ability to induce clinically apparent
illness

Virulence – Defined as the proportion of clinical cases

resulting in severe clinical manifestation
(including sequelae)

The case fatality rate is one way of measuring

virulence
2. Nutrient agents:

- can be proteins, fats, Carbohydrate, vitamins,

minerals & water

- Any excess or deficiency of the intake of

nutritive elements may result in nutritional
disorders.

- PEM, Anaemia, goitre, obesity & vitamin

deficiencies
3. Physical agents :

-Exposure to excess heat cold, humidity, pressure,

radiation, electricity, sound etc., may result in
illness.
4. Chemical agents:

i. Endogenous- Some of the chemicals may be produced

in the body as a result of derangements of function

Eg: urea – uremia

Serum bilirubin - Jaundice
Ketones - Ketosis
Uric acid – qout
Calcium carbonate – Kidney stones
ii. Exogenous agents arising outside of human host

Eg: allergens
metals
fumes
dust
gases
insecticides etc.

-Acquired by inhalation
ingestion
or
inoculation
5. Mechanical agents:

Exposure to chronic friction & other mechanical

forces may result in crushing, tearing, sprains,
dislocations & even death.
 6. Absence or insufficiency or excess of a factor
necessary to health:

i. Chemical factors – hormones

- enzymes
ii. Nutrient factors
iii. Lack of structure eg: Thymus
iv. Lack of part – eg: Cardiac defects
v. Chromosomal factors eg: mongolism turner’s syndrome
vi. Immunological factors eg: agammaglobinaemia
Host Factors
Classified as -
i. Demographic such as age, sex, characteristics
ii. Biological characteristics – Genetic factors
- Biochemical eg: levels of
cholesterol the blood
- Blood groups
- Cellular constituents of
the blood
- Immunological factors
- Physiological function of
different systems of the
body
iii. Social & Economic characteristics

- S.E.S

- Education

- Occupation

- Stress

- Marital status

- Housing
iv. Life style factors
- Personality traits & behavioural patterns

- Living habits
- Nutrition
- Physical exercise
- Use of alcohol, drugs & smoking
Environmental factors (Extrinsic)

The external or macro-enivronment is defined as

“ all that which is external to the individual human
Host, living & non living & with which he is in
Constant interaction.

-Includes all of man’s external surroundings such as

air, water, food, housing etc,.
-For descriptive purpose, the environment divided into
three components

- Physical

- Biological
- Psychosocial
a. Physical Environment:

Applied to non living things & physical factors

Eg: air, water, soil, housing, climate, geography, heat,

light, noise, debris, radiation etc.

Improvement of physical environment has been

Responsible for most of the improvement in health
during the part.
Man has altered practically everything in his physically
everything in his physical environment for his advantage
& has created a host of new health problems like air
pollution, water pollution, noise pollution, urbanization,
radiation hazards etc.,

The increasing use of electrical & electronic devices,

including the rapid growth of telecommunication system

eg: Satellite systems, radio broadcasting, television trans-

-mitters & radar installations have increased the
exposure to electromagnetic energy.
b. Biological Environment:

Includes the various living things like viruses, microbes

insects, rodents, animals & plants.

Some of them act as disease producing agents, reservoirs

Of infection, intermediate hosts & vectors of diseases.

When there is ecological maladjustment between these

members it results in ill health.
c. Psycho-social environment
Psycho-social factors are those factors affecting personal
health, health care & community well being that stem
from the psycho social make up of individuals & the
structure & functions of social groups.

They include cultural values customs, habits, beliefs,

attitudes, morals, religion, education, lifestyle, community
life, health services, social & political organization.
Man is a member of a social group, the member of family,
of a caste, of a community & of a nation.

Between the individual & other members of the group,

there can be harmony or disharmony, interests & points
of view that are shared that are in conflict and can yield
great distress.

Psychosocial factors can affect negatively man’s

health & well being , for example, poverty, migration,
exposure to stressful situations such as bereavement,,
loss of employment, birth of handicapped child may
Produce feelings of anxiety, depression, anger, frustration,
& so forth, and these feeling maybe accompanied by
physical symptoms such as headache, palpitations etc .
The psychosomatic disorders include conditions such
as duodenal ulcer, bronchial asthma, Hypertension, CHD,
mental disorders.

Eg: Medical cause of lung cancer may be a chemical

substance in cigarettes, but the psychosocial cause is
behaviour

-Why people start smoking and continues to smoke.

It is all together a behavioural disorder.
 Risk factors:

When the disease agent is not firmly established, the

aetiological factors are generally discussed in terms
of risk factors

“Risk factor” is an attribute or an exposure that is

significantly associated with the development of a disease

A determinant that can be modified by intervention thereby

reducing the possibility of occurrence of disease or other
specified outcomes
 Presence of risk factor does not imply that disease will
occur & in its absence, the disease will not occur.
Eg: smoking & hypertension & high blood cholesterol
- CHD
Risk factors may be -
- causative
Eg.: smoking for lung cancer
- contributory
Eg.: lack of physical exercise for CHD
- predictive only in a statistical sense
Eg.: illiteracy for perinatal mortality
Contd...

- modifiable – smoking, HTN elevated serum

cholesterol obesity, Amenable to intervention

- not modifiable– age, sex, race family history and

genetic factor are not subject to change
 Risk factors may be -

a. Individual risk factors – includes age, sex, smoking, HTN

b. Community risks Eg: from presence of air pollution,

substandard housing poor water supply & sanitation
- Case control & cohort studies are needed to identify risk
factors & estimate the degree of risk.

- Detection of risk factors should be considered a prelude

to prevention or intervention

For each risk factor ascertained, the question asked

whether it can reduced in a cost effective way & whether
its reduction will prevent or delay the outcome
Risk groups or target groups

WHO promoted to identify risk groups

Eg: at risk mothers, at risk infants, at risk families
Elderly, handicapped, in the population by certain
defined criteria & direct appropriate action to them first

“Something for all, but more for those in need”

WHO using risk approach in MCH services.

Spectrum of disease
“Gradient of infection”.

-A graphic representation of variations in the

manifestations of disease.

Sub clinical Mild to severe Fatal

Infectious Illness illnesses
(clinical cases)

These different manifestations are simply reflection of

individuals different states of immunity & receptivity.
Iceberg of disease

Ice cube

Water

- A concept closely related to the spectrum of disease

- The disease in a community may be compared with

an iceberg

- The floating tip of iceberg represents what the physician

sees in the community i.e. clinical cases.
Submerged portion of the iceberg represents the hidden
mass of disease
i.e latent, in apparent, presymtomatic & undiagnosed cases
& carriers in the community

“Waterline” represents the demarcation between apparent

& in apparent disease”.

The detection & control of the undiagnosed portion is

the major challenge to modern technique in “preventive
Medicine”.