Natural History of

Disease and Patterns of

Infection

Alissa Laurel N. Calderon, MD, FPAFP, MMHA

 Session Objectives
v  To review the theories of disease causation
v  Differentiate the various models of disease

causation: triangle, wheel and web

models
v  To review the scope of the natural history of
infection
v  To describe the natural history of infection in
terms of the pre-pathogenetic phase, incubation
period and pathogenetic phase.
Concepts of Disease Occurrence
v  Diseaseand other health events do not
occur randomly in a population
–  Some more likely to occur - because of risk
factors
 Theories of Disease Causation
v  Disease was due to evil spirits
v  Recovery was attributed to good spirits

v  Disease as a form of punishment

v  Control measures include offering sacrifices

and “casting-out demons”
 Theories of Disease Causation
Filth Theory “Bad air”
v  Associates disease with v  was the cause of fever .

the physical environment v  Building huge fires can

v  Disease change with purify the air

seasons, climate, v  Programs to remove filth
temperature, likewise put up to serve to
overcrowding and filth advance community
v  Diseases were due to sanitation.
poisonous substances and
gases from the earth
 Theories of Disease Causation

v  Germ or v  Opened the concepts of

Bacteriological Theory isolation and quarantine
v  Koch confirmed v  Measures to destroy and
Pasteur’s previous remove the
bacteriological cause
claims such as disinfection ,
v  Disease is due to fumigation and general
microscopic forms of cleanliness
life v  Bacteriology –explained
the origins and spread of
communicable disease
 Theories of Disease Causation

Concept of Multiple causation

v  Disease results from the interaction of
multiple ecologic factors within a dynamic
system made up of an agent of disease, host
and the environment
 The Epidemiologic Lever

Agent Host

Environment
 Host

Agent

Environment
The Epidemiologic Triangle
Agent

Host Environment
 Epidemiologic Triad/Triangle
v  Agent– infectious microorganism/
pathogen/chemical and physical causes
–  Should be present for disease to occur
–  Presence alone is not sufficient to cause disease
–  Factors that influence whether exposure to
agent will result to disease:
•  Organism’s pathogenicity
•  dose
 Epidemiologic Triad/Triangle
v  Host– refers to the human who can get the
disease
•  Risk factors
v  behaviours
 Epidemiologic Triad/Triangle
v  Environment – extrinsic factors that affect
the agent and the opportunity for exposure
–  Physical factors – geology, climate
–  Biologic factors - insects
–  Socioeconomic factors
•  Crowding, sanitation, availability of health services
•  disease never depends on a
single isolated cause
•  developed as a result of chain of
complex interactions of factors
like biophysical, social and
psychological
Component Causes and Causal Pies
v  Proposed by Rothman in 1976
v  Component cause – an individual factor that
contributes to cause disease; a piece of pie
v  Sufficient cause- complete pie leading to
disease occurrence; all the pieces fall into
place
–  Considered a causal pathway
v  Necessary cause – a component cause that
appears in every pie or pathway
–  Without it a disease will not occur
4 Types of Factors of Disease Causation
1.  Predisposing factors – are those that may
create a state of susceptibility to a disease
e.g. age, sex, previous illness
2.  Reinforcing factors- are those that may
aggravate an established disease or state.
e.g. repeated exposure, unduly hard work
3.  Enabling factors- are those that favor the
development of disease, assist in recovery or
health maintenance
4.  Precipitating factors- are those that are
associated with onset of disease.
e.g. exposure to a specific disease agent or
noxious substance
 Natural History
(The Timeline of a Disease)

v  The progression of
disease through
successive stages
often used to
describe the course
of an illness for
which no effective
treatment is
available
 Why Study the Natural History
v  After being informed of the doctor’s
diagnosis, the question most patients
frequently ask “What will happen to me?”
v  The best guidance for predictions is the
experience of other patients who are similar
to the patient in question.
 Importance of Knowing
the Natural History
Preventive value- prevention at any level depends
on the knowledge of multiple causes related to the
agent, host and environmental factors and correct
application of knowledge.
Prevention requires interposition of various kinds
of barriers to the interaction of the host , agent and
environment.
Prognostic value- . The outcome of a disease will
depend upon early recognition, promptness of
treatment, level of competence of the health
professional and availability of facilities .
 Me too !
Oh I had Rash
chickenpox once ! only ! But all I had
I had cough, colds, was just
fever, sore throat, rash..?
fatigue,
vomiting….and
rash.. and ….
 Scope of Natural History
v  Comprises the body of knowledge about the
agent, host and environmental factors
relating to the disease process.
v  Includes forces/factors which initiated the
process in the environment through the
resulting changes which took place in man
until continuing equilibrium is reached or
defect, disability or death ensues.
 Scope of Natural History
v  Familiarity with the natural history prepares the
epidemiologist to institute control measures
needed.
v  Helps in the analysis of findings and guides him
the in control programs
v  All medical officers must be familiar with the
natural history of all common diseases in their
respective assignments
v  Discover gaps in knowledge and address them in
research
 Phases of the
Natural History of Disease
v  Pre-pathogenesis
–  Phase before man is involved
–  Interaction of the three forces, the agent finally
reaches man
–  “everyone is in a period of pre-pathogenesis”
–  E.g. Strong winds blow anopheline mosquitoes
from an endemic area to an area which is non-
malarious
 Phases of the
Natural History of Disease
v  Pathogenesis
–  Includes the successful invasion and establishment
of the agent in the host.
–  2 phases:
•  Incubation Period- the lapse of time between the entry
of the agent and the manifestations of the disease
•  Clinical Horizon- phase where the agent multiplies,
develops in the host’s tissues and initiate physiological
reactions . The stage when clinical diagnosis can be
made. The disease may not reach the clinical horizon
and terminate in recovery, disability or death.
 PRE-PATHOGENESIS PATHOGENESIS
The course of disease in man
Before man is diseased Death

Chronic State
Interaction of the
Convalescence Disability
Disease Human
agent host Advanced disease Recovery

Discernible early disease

Environmental factors Clinical
Horizon Early Pathogenesis

which produces disease Interaction of Host & Stimuli

stimulus
 The Process of Infection
In case of infections, there are 6 requirements for the
successful invasion of the host by the infectious
agent.
1.  Conditions in the environment must be favorable to the
agent of the agent must be able to adopt to the environment
2.  Suitable reservoirs must be present
3.  A susceptible host must be present
4.  Satisfactory portal of entry into the host
5.  Accessible portal exit from the host
6.  Appropriate means of dissemination and transmission
 THE PROCESS OF INFECTION IN MAN
The host-parasite relationship is reflected in
the disease process itself; the manifestation
depends on the ff:

1. Characteristics of the agent

2. Dose of the agent
3. Duration of exposure
4. Reaction of the tissue of the host
5. Portal of entry & tissue affected
 The Chain of Infection

Cutting a part
of the chain may
stop the
transmission
 Characteristics of the Agent
Directly Related to the Host
1. Antigenicity- the ability to induce antibody
production
2. Toxicity- the ability to produce toxin
3. Invasiveness- the ability to penetrate or grow
within the host away from the original site of
illness
4. Virulence- the ability to cause serious illness
5. Pathogenicity- the ability to cause disease
6. Infectivity- the ability to lodge
and multiply in the body of the host
 CHAIN OF INFECTION
Infectious Agent
Mode of Transmission
Portal of Entry
Susceptible Host
Portal of Exit
 MODE OF TRANSMISSION
•  Direct
o  Direct contact
o  Droplet spread

•  Indirect
o  Airborne
o  Vehicle-borne
o  Vector-borne (mechanical or biologic) -
 Mechanisms of Transmission

Direct contact (person-to-person)Skin,

saliva via kissing, sexual contact, aerosol from
sneezing or coughing
v  Polio, hepatitis, HIV, influenza
MECHANISMS OFTRANSMISSION
Indirect contact
•  vector (an organism that carries disease-
causing micro-organisms, such as mosquito),
dust particles, air, food, water, blood, tissues,
•  organs, fomites (inanimate objects that can
carry disease-causing micro-organisms—e.g.,
toothbrush, cutting board, toys, etc. )

v Diseases that are commonly spread by means of fomites

include the common cold, cold sores, conjunctivitis,
coxsackievirus (hand-foot- mouth disease), croup, E. coli
infection, Giardia infection, influenza, lice, meningitis,
rotavirus diarrhea, RSV, and streptococci
 PORTAL OF ENTRY

•  refers to the manner in which a pathogen

enters a susceptible host.

•  A suitable portal of entry is a requisite for

a successful parasitism.

•  Often, infectious agents use the same

portal to enter a new host that they used
to exit the source host.
 Portal of Entry and Portal of Exit
Oral cavity

Respiratory Tract- droplet borne diseases such as

tuberculosis. Whooping cough, measles, diphtheria
Skin and mucous membranes- STD, rabies, wound
infection, scabies and mycotic infections. The conjunctiva
is a portal for ophthalmia neonatorum and trachoma. The
placenta may act as a portal for rubella syphilis,
cytomegalovirus from the infected mother to the fetus
Portals of Entry and Exit
 SUSCEPTIBLE HOST
v  HOST – an individual exposed to the
agent
–  refers to human who can get the disease
(CDC)

v  Susceptibilityof a host depends on

genetic or constitutional factors, specific
immunity, and nonspecific factors that
affect an individual’s ability to resist
infection or to limit pathogenicity
 Incubation Period
v  The interval between the time of entry of
the agent into the host and the onset of signs
and symptoms of disease

v  Represents the time required for the parasite

to establish itself to multiply and secrete
toxins. (as opposed to actions of chemical
toxins or poisons)
 The Incubation Period
v  Varies from one disease to another
v  Useful tool in the DIFFERENTIAL
DIAGNOSIS (e.g. infectious hepatitis and
serum hepatitis), as well as determining the
possible time and source of exposure
 The Incubation Period
Varies according to the following factors:
1.  Agent virulence, dose and portal of entry
e.g. Rabies patients bitten in the face – the IP was
35 days while those bitten other than the face (legs)
IP was 60 days and up.
2.  Previous host experience and natural resistance
Development of previous immunity, tolerance or
premunition (refractoriness) to the disease
3.  Inherent characteristics of the agent or organism
e.g. Plasmodium vivax with a short IP of 10-15 days
and P. malariae of 28-37 days
 Clinical Manifestations of
Communicable Disease
(Clinical Horizon)

v  Signs and symptoms of infection

–  Fever (continuous, remittent, intermittent)
 Outcome of Disease
1.) Recovery
2.) Chronicity
3.) Carrier state
4.) Temporary or permanent disability
5.) Death
 Period of Communicability
v  The time period during which the patient is
very infectious. It is very short in certain
diseases (e.g. 3 days in influenza from
clinical onset) and long in diseases in which
carrier should be closely supervised
 Carriers
v  Arepersons who harbor a specific
infectious agent in the absence of clinically
evident disease and serve as a potential
source or reservoir of infection for man.
 Types of Carriers

v  Incubatory carrier – when they are

infective during the IP (e.g. in measles – 4
days before the rashes appear)
v  Convalescent carrier- when the carrier
state occurs during convalescence. The
patient although asymptomatic continue to
excrete organisms and infect others (e.g.
typhoid, malaria diphtheria)
 Types of Carriers

v  Temporary carrier – when the carrier state

is transient or temporary . E.g. cholera

v  Chronic carrier- long year being a carrier

(e.g. typhoid fever, hepatitis B) This state
must be recognized for preventive services.
 THE PROCESS OF INFECTION IN MAN
Possible results of infection:
1. Recovery- the host was able to ward off the
infection or disease agent
2. Balanced equilibrium- the forces of the
agent and the host are equal so both are not
affected. This is dangerous because the host
becomes a healthy carrier (inapparent
infection)
3. Subclinical conditions- very mild reactions
that escape detection
4. Clinical case- full-blown case which may
either be atypical or typical
Natural History of Disease
 OUTCOME OF THE DISEASE
Clinical Case

Recovery Death

Chronic condition
Complete Carrier state

Defect/temporary or
permanent disability
Thank You!!!