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WEB OF CAUSATION
The causes of most diseases are more complex than simply an interaction between a host, agent
and environment. To explain disease and disability caused by multiple factors, Mac Mahon and
Pugh (1971) developed the concept of "chain of causation”, later termed the “web of causation."
Chronic diseases such as coronary artery disease and most types of cancer are not attributable to
one or two factors alone. Rather, the interaction of multiple factors is necessary to produce the
disease.
The web of causation can also be applied to many health-related threats and conditions. The
problem of teenage pregnancy, for example, is attributable to a complex interaction between a
number of causative and contributing factors, including lack of knowledge about sexuality and
pregnancy prevention, lack of easily accessible contraception, peer pressure to engage in sex,
low self-esteem, social patients that encourage early motherhood, and use of alcohol or other
drugs. Patterns of family violence, cocaine use, and gang membership are examples of other
threats to health and well-being that can be more accurately explained through a multiple-
causation model.
Recognition that many health problems have multiple causes leads to the recognition that simple
solutions to these health problems rarely exist. When trying to manage teenage pregnancy, for
example, the solution is not as simple as addressing a "knowledge deficit about sexuality and
contraception. Many (if not most) teens are well informed about contraception and the mechanics
of how one gets pregnant and still fail to take preventative measures.
To prevent heart disease in an individual at risk, interventions include health education
addressing a number of areas, including smoking cessation, reduction of blood pressure, weight
loss, cholesterol reduction, and exercise. Interventions might also need to address life style,
stress management, social support, and personality traits, among others. Likewise, to prevent
teenage pregnancy, interventions should include health teaching on improving self- esteem; role-
playing exercises on how to say "no"; encouraging an orientation to the future; enhancing
parental supervision; and providing recreational alternatives (sports and other after school
activities) in addition to giving information on sexuality, the mechanics of reproduction, and
methods of contraception
FACTORS IN CAUSATION OF DISEASE
Selected factors have been useful in assessing the causation of disease at the community level
predisposing factors, enabling factors, precipitating factors, and reinforcing factors.
1. Predisposing factors: These are the factors or conditions already present that produce a
susceptibility or disposition in a host to a disease or condition without actually causing it. lf
the host is immunized against the disease or if the host has a natural resistance to the disease,
he or she will respond by not getting the disease. If not protected, the host will respond by
getting the disease because of exposure to the pathogen or agent. If sensitized to a condition,
the host will respond accordingly. For example, if the host has an allergic sensitization to a
substance and then is exposed to the substance, an allergic reaction will follow.
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2. Enabling factors: These factors or conditions allow or assist the disease, condition, injury,
disability, or death, letting the process begins and run its course. Some of the factors that can
enable a disease to spread can be the lack of public health and medical care.
3. Precipitating factors are essential to the development of diseases, conditions, injuries,
disabilities, and death. Such as exposure to a specific disease agent may be associated with
the onset of a disease.
4. Reinforcing factors have the ability to support the production and transmission of disease or
conditions, support and improve a population’s health status and help control diseases and
conditions. Such as repeated exposure, environmental conditions and unduly hard work may
aggravate an established disease or injury.

THE ICEBERG MODEL

The”iceberg model" or”iceberg principle" describes the phenomenon that at any given time there
are a small number of known cases of a disease or condition at the early and advanced stages.
These known cases are those that are visible. However, like the iceberg, the greatest threat comes
from the greater amount of unknown cases (i.e. those that are not identified).
Infection with human immunodeficiency virus (HIV) is an excellent illustration of this principle.
The clinically diagnosed cases of acquired immunodeficiency syndrome (AIDS) (manifest
disease) represent only a small fraction of all cases of those infected. Those known to have HIV
infection (mild, atypical disease) make up a more significant part of the whole, but the greatest
concern, and possibly the greatest threat, comes from those individuals who have not been
diagnosed and may be transmitting HIV unknowingly
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OUTBREAK INVESTIGATIONS
Outbreak: It is a term used in epidemiology to describe an occurrence of disease greater than
would otherwise be expected in a particular time and place.
Outbreak investigations, an important and challenging component of epidemiology and
public health, can help identify the source of ongoing outbreaks and prevent additional cases.
Even when an outbreak is over, a thorough epidemiologic and environmental investigation often
can increase our knowledge of a given disease and prevent future outbreaks. Finally, outbreak
investigations provide epidemiologic training and foster cooperation between the clinical and
public health communities.
How are outbreaks recognized?
There are recognized by;
1. Practitioners (astute (intelligent) clinician, infection control professional, laboratory worker)
2. Patient or patient's family
3. Public health surveillance data (uncommon)
4. Local media (newspaper and television)
Reasons for investigating outbreaks
1. Prevent additional cases in current 4. Learn something new about an old
outbreak disease
2. Prevent future outbreaks 5. Reassure the public
3. Learn about a new disease 6. Minimize economic & social disruption
7. Teach epidemiology
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Steps of an Outbreak Investigation
When investigating disease outbreaks, the epidemiology profession has developed a number of
widely accepted steps. As described by the Centers for Disease Control and Prevention, these
include the following.
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
a. establish a case definition
b. identify and count cases
5. Perform descriptive epidemiology
6. Develop hypotheses
7. Evaluate hypotheses
8. As necessary, reconsider/refine hypotheses and execute additional studies
a. additional epidemiologic studies
b. other types of studies – laboratory, environmental
9. Implement control and prevention measures
10. Communicate findings

Constraints (limitations) of field outbreak investigation

● Urgency to find source and prevent cases
● Pressure for rapid conclusion
● Statistical power often limited
● Media reports may bias interviewees
● Pressures because of legal liability
● Pressures because of financial liability
● Delays lead to limited human or environmental samples for testing