NATURAL HISTORY OF

DISEASE

INTRODUCTION

Natural history of disease refers to the

progress of a disease process in an individual
over time, in the absence of treatment or
prevention.
It is an key concept in Epidemiology
Each disease has its own, unique natural
history.

PHASES OF DISEASE

Pre-Pathogenesis
Disease
Process

PRE-PATHOGENESIS

This refers to the period preliminary to the

onset of disease in man.
Process of disease in the environment
This situation usually referred to as Man in
the Midst of disease
The disease agent has not yet entered man,
but the factors which favor its interaction with
the human host are already existing in the
environment.

WHAT IS REQUIRED IS THE INTERACTION OF THESE

THREE FACTORS I.E. AGENT, HOST AND ENVIRONMENT
TO INITIATE THE DISEASE PROCESS IN MAN.

PATHOGENESIS PHASE
The pathogenesis phase begins with the entry of the disease
agent in the susceptible human host. The disease agent
multiplies and induces tissue and physiological changes, the
disease progresses through a period of incubation and later
through early and late pathogenesis .

It is useful to remember at this stage that the hosts reaction

to infection with disease agent is not predictable. That is the
infection may be

Clinical or subclinical

Typical or Atypical

Or the host become carrier with or without having

developed clinical disease as in the case of diphtheria and
hepatitis B

FACTORS
1.Agentfactors
Asubstance,livingornonliving,ora

force, tangible or intangible, the

excessive presence or relative lack of
which may initiate or perpetuate a
diseaseprocess.

Agents
Biological

TYPES OF AGENTS

Contd

Biological agents:
These are living agents of disease, viruses, rickettsiae,
fungi, bacteria, protozoa and metazoa.
These agents exhibit certain host-related

Biological properties such as:

Infectivity:
This is the ability of an infectious agent to invade
multiply in a host:

and

Cont

Pathogenicity : This is the ability to induce clinically

apparent illness..

Virulence: the proportion of clinical cases resulting in

severe clinical manifestations

Nutrient agents:- These are proteins, fats, carbohydrate,

minerals and water. Any excess or deficiency of the intake of
nutritive elements may result in nutritional disorders. e.g.
Anaemia, goitre, obesity and vitamin deficiencies are some of
the current nutritional problems in many countries.

Physical agents:-Exposure to excessive heat, cold, humidity,

pressure, radiation, electricity, sound.

Contd.

Chemical agents :-

Endogenous: e. g. Ureamia, jaundice, ketosis.

Exogenous : e. g. allergens, metals, fumes.

Mechanical agents:- Exposure of chronic friction and

other mechanical forces may result in crushing, tearing,
sprains, dislocations and even death.

Cont..
Absence or insufficiency or excess of a factor
necessary to health
These may be:
(i)
Chemical factors
(ii) Nutrient factors

(iii) chromosomal factors

(iv) Immunological factors.
Social agents:- It is also necessary to consider agents of
disease. These are poverty, smoking, abuse of drugs and
alcohol, unhealthy lifestyles, social isolation, maternal
deprivation

()

2HOSTFACTORS
The human host is referred to as soil and the disease
agent as seed . In some situations, host factors play a
major role in determining the outcome of an
individuals exposure to infection.eg. Tuberculosis.
The host factors may be classified as;

Demographic

Biological

CONT

Social and economic characteristics such as

socioeconomic status, education, occupation, stress ,
marital status , housing, etc.

Lifestyle factors such as personality traits , living

habits, nutrition, physical exercise, use of alcohol,
drugs and smoking, behavioral patterns.

3ENVIRONMENTAL FACTORS
For human beings the environment is not limited, as
it normally is for plants and animals, to a set of climatic
factors.
For Example, for man, social and economic
conditions are more important than the mean annual
temperature.

CONT.

Physical
Biological
Psychosocial.

Physical environment:

The term physical environment is applied to non-living

things and physical factors (e.g.. Air, water, soil, housing,
climate, geography, heat, light, noise, debris & radiation)

CONT.
Biological environment:- The biological environment
is the universe of living things which surrounds man,
including man himself. The living things are the viruses
and other microbial agents, insects, rodents animals and
plants

Psychosocial environment:- Those factors affecting

personal health, health care and community well-being that
stem from the psychosocial make-up of individuals and the
structure and functions of social groups.

Risk factor
a.

An attribute or exposure that is significantly associated

with the development of a disease.

b. A determinant that can be modified by intervention,

thereby reducing the possibility of occurrence of disease
or other specified outcomes.

Risk groups
Biological situation:

age group, e.g., infants (low birth weight),

toddlers, elderly

sex, e.g., females in the reproductive age period

physiological state, e.g., pregnancy, cholesterol

level, high blood pressure

genetic factors, e.g., family history of genetic

disorders

CONT
b. Physical situation:
Rural, urban slums
Living conditions , overcrowding
Environment: water supply, proximity to industries
c. Sociocultural and cultural situation:
Social class
Ethnic and cultural group
Family disruption. Education, housing
Customs, habits and behavior
Lifestyles and attitudes
Access to health services

SPECTRUM OF DISEASE
The term spectrum of disease is a graphic representation of
variations in the manifestations of disease.

ICEBERG OF DISEASE
The floating tip of the iceberg represents what the
physician sees in the community, i.e., clinical
cases. The cast submerged portion of the iceberg
represents the hidden mass of disease, i.e., latent,
inapparent, presymptomatic and undiagnosed
cases and carriers in the community. The
waterline represents the demarcation between
apparent and inapparent disease.

Symptomatic disease
( what the physician sees)

Pre-symptomatic disease
(what the physician does not see)

THEORIES OF DISEASE
CAUSATION

THEORIES OF DISEASES CAUSATION

1.

Supernatural theory of disease

Disease is due to super power e.g. gods, evil spirits.

2.

Tridosha theory of disease

The doshas or humors are: Vaata (Wind), Pitta (gall),
and Kapha (mucus).
Perfect balance of tridosha is healthy
Disturbance in balance is disease

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3.

Theory of Contagion

Spreading of disease by being close to or touching

other people.

4.

Miasmatic theory of disease causation

Disease is due to noxious air and vapors

These concepts were prevailing before Louis Pasteur

(1822-1895).

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Germ Theory of disease:

5.

In 1860, Louis Pasteur demonstrated the presence of bacteria

in air.
This theory emphasized that the sole cause of disease is
microbes.
The theory generally referred to as one-to-one relationship
between disease agent and disease.

Disease agent

Man

Disease

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Epidemiological Triad concept

6.

The germ theory of disease has many limitations

For example it is well known that not all exposed to
tuberculosis bacilli develops tuberculosis ,the same
condition in an undernourished person may result in
clinically manifest.

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EPIDEMIOLOGICAL TRIAD
Environment

Agent

Host
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MULTI-FACTORIAL ETIOLOGY

The germ theory of disease or single cause of disease is

always not true.

The germ theory of disease was overshadowed by multifactorial cause theory in 19th century.

As a result of advancement in public health, communicable

diseases began to decline and are replaced by new type of
diseases so called modern disease of civilization.

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MULTI-FACTORIAL ETIOLOGY

Example: Lung cancer, CHD, Mental illness etc. The

disease could not be explained on the basis of germ theory
of disease and can not be controlled or prevented on that
basis. The realization began that multiple factors are
responsible for disease causation where there is no clear
single agent.

The purpose of knowing multiple factors of disease is to

quantify and arrange them in priority sequence for
modification to prevent particular disease.

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WEB OF CAUSATION

This model of disease causation was suggested by Mac

Mohan and Pugh.

]This model is ideally suited in the study of chronic disease

where the disease agent is often not known, but is the
outcome of interaction of multiple factors.

The web of causation considers all the predisposing factors

of any type and their complex interaction with each other.

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WEB OF CAUSATION

The basic tenets of epidemiology are to study the clusters

of causes and combinations of efforts and how they relate
to each other.

The web of causation does not imply that the disease can
not be controlled unless all the multiple causes or chain of
causation or at least a number of them are appropriately
controlled.

Sometimes, removal of one link may be sufficient to

control disease.

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WEB OF DISEASE CAUSATION

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Factors of disease
causation

FACTORS OF DISEASE CAUSATION

a) Predisposing factors are factors which create a state of

susceptibility, so that the host becomes vulnerable to the
agent or to necessary cause, e.g. age, sex, previous illness.

b) Enabling factors are those which assist in the

development of (or in recovery from) the disease; e.g.
housing conditions, socio-economic status.

c) Precipitating factors are those

which are associated with immediate
exposure to the disease agent or onset
of disease, e.g. drinking contaminated
water, close contact with a case of
pulmonary TB.

FACTORS OF DISEASE CAUSATION

d) Reinforcing factors are those which aggravate an already existing

disease, e.g. malnutrition, repeated exposures

e) Risk factors : A risk factor is defined as a condition, quality or

attribute, the presence of which increases the chances of an
individual to have, develop or be adversely affected by a disease
process. A risk factor is not necessarily the cause of a disease but
does increase the probability that a person exposed to the factor may
get the disease.

Exposure to
TB

No infection(70-90%)

Infection(10-30%)

Latent TB (90% well)

-Never develop TB
-Not infectious

Active TB(10% ill)

-5% develop TB within 2 years
-5% develop TB many years later

Untreated
Treated
50% die within 5 years
25% remain sick
25% recover

Cured

CONCEPT OF CONTROL

CONCEPT OF CONTROL

DISEASE CONTROL: The term disease control refers

ongoing operation aimed at reducing:
The incidence of disease.
The duration of disease and the consequently the risk of
transmission.
The effect of infection including physical and
psychological complication.
The financial burden to the community.

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CONCEPT OF CONTROL

In disease control, the disease agent is permitted to persist

in the community at a level where it ceases to be a public
health problem according to the tolerance of local
community. For example Malaria control programme.
Disease control activities focus on primary prevention

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CONCEPT OF CONTROL
ELIMINATION: Reduction of case transmission to a
predetermined very low level or interruption in
transmission. E.g. measles, polio, leprosy from the large
geographic region or area.
ERADICATION: Termination of all transmission of
infection by extermination of the infectious agent through
surveillance and containment. All or none phenomenon.
E.g. Small pox

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CONCEPT OF CONTROL

MONITORING: Defined as the performance and

analysis of routine measurement aimed at detecting
changes in the environment or health status of
population. e.g. growth monitoring of child, Monitoring
of air pollution, monitoring of water quality etc.
SURVEILLANCE: Defined as the continuous scrutiny
of the factors that determine the occurrence and
distribution of disease and other conditions of ill health.
E.g. Poliomyelitis surveillance programme of WHO.

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TYPES OF SURVEILLANCE

Passive surveillance: receipt of reports of

infections/disease from physicians, laboratories
and other health care professionals required to
submit such reports as defined by public health
legislation

Active surveillance: Active disease surveillance

is also based on public health legislation and
refers to daily, weekly or monthly contacting of
physicians, hospitals, laboratories, schools or
others to actively search for cases
Usually

seasonal or done during disease outbreaks

CONCEPT OF
DISEASE

CONCEPT OF DISEASE

Webster defines disease as a condition in which body

health is impaired, a departure from a state of health, an
alteration of the human body interrupting the performance
of vital functions.

The oxford English Dictionary defines disease as a

condition of the body or some part or organ of the body in
which its functions are disturbed or deranged.

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Ecological point of view disease is defined as a maladjustment

of the human organism to the environment.

The simplest definition is that disease is just the opposite of

health: i.e. any deviation from normal functioning or state of
complete physical or mental well-being.

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DISTINCTION BETWEEN DISEASE,

ILLNESS AND SICKNESS

The term disease literally means without ease

(uneasiness), when something is wrong with bodily function.

Illness refers to the presence of a specific disease, and also to

the individuals perceptions and behavior in response to the
disease, as well as the impact of that disease on the
psychosocial environment.

Sickness refers to a state of social dysfunction.

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DISTINCTION BETWEEN DISEASE,

ILLNESS AND SICKNESS

Disease is a physiological/psychological dysfunction.

Illness is a subjective state of the person who feels aware

of not being well.

Sickness is a state of social dysfunction i.e. a role that the

individual assumes when ill (sickness role).

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