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Concept of disease
- 2. 2 CONCEPT OF DISEASE Dr Nabeela Basha Seminar - 7
- 3. CONTENTS INTRODUCTION CONCEPTS OF DISEASE CONCEPTS OF CAUSATION NATURAL HISTORY OF DISEASE CONCEPTS OF CONTROL CONCEPTS OF PREVENTION CHANGING PATTERN OF DISEASE CONCLUSION REFERENCES PREVIOUS YEAR QUESTIONS 3
- 4. 4 • Disease the word itself has a negative vibe and recalls a memory of suffering. • Earlier disease was viewed as an curse or punishment for sins committed by man i.e. it has its own fear factor. • Later perceptions on disease were changed . It is now viewed as a channel to explore more crevices in understanding human body its capabilities, limitations, interactions etc. • The concept of disease has been the subject of a vast, vivid and versatile debate.
- 5. 5DEFINITIONS “A condition in which body function is impaired, departure from a state of health, an alteration of the human body interrupting the performance of the vital functions.” “The condition of body or some part of organ of body in which its functions are disrupted or deranged.” “Disease is considered a social phenomenon, occuring in all societies and defined and fought in terms of the particular cultural forces prevalent in the society.” ‘a maladjustment of human organism to the environment’
- 6. TO KEEP IT SIMPLE Simplest definition – OPPOSITE TO HEALTH . 6 Any deviation from normal functioning or state of complete physical or mental well-being.
- 7. DISEASE ILLNESS SICKNESS7 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). Susser
- 8. 8 WHO has defined health but not disease, because of the following limitations? • Disease has got many shades(spectrum) • Onset – acute or chronic • Healthy outside infect others carriers…..
- 9. 9 • The same pathogen - more than one disease (eg:streptococci). • The same disease - more than one organism (e.g. diarrhoea). • The course of the disease may be short or prolonged • It is difficult to demarcate between normal and abnormal state as in hypertension, diabetes, mental illness, etc. • The final outcome of the disease isvariable, i.e. recovery, disability or death.
- 10. SOCIAL SIGNIFICANCE OF DISEASE Living with disease is very difficult. Disease has significant social or economic implications. Lepers - group of afflicted individuals, historically shunned and the term "leper" still evokes social stigma. Fear of disease can still be a widespread social phenomena, though not all diseases evoke extreme social stigma. 10
- 11. Sickness confers the social legitimization of certain benefits, such as illness benefits, work avoidance, and being looked after by others. In return, there is an obligation on the sick person to seek treatment and work to become well once more. 11
- 12. As a comparison, consider pregnancy, which is not a state interpreted as disease or sickness by the individual. On the other hand, it is considered by the medical community as a condition requiring medical care and by society at large as a condition requiring one's staying at home from work. 12
- 13. Disease can be……. INFECTIOUS – resulting from infection. CONTAGIOUS –Transmitted through contact. eg: scabies, trachoma, leprosy, STD. COMMUNICABLE – Illness due to specific infectious agent or its toxic products capable of being directly or indirectly transmitted from man to man, animal to animal or from environment to man or animal (through air, dust, soil, water, food, etc) 13
- 14. ENDEMIC : (en: in , demos: people) It refers to constant presence of a disease or infectious agent with a given geographic area or population group, without importation from outside. eg: common cold. SPORADIC – Cases that occur irregularly, haphazardly from time to time, and generally infrequently. eg: Tetanus, herpes zoster, meningococcol meningitis. 14
- 15. EPIDEMIC : The unusual occurrence in a community or region, of disease, specific health related behavior or other health related events clearly in excess of normal expected occurrence. eg: MERS, Ebola virus disease, Typhus 15
- 16. PANDEMIC – An epidemic usually affecting large population, occurring over a wide geographic area such as section of nation, the entire nation, a continent or the world. eg: influenza, cholera, 16
- 17. CONCEPT OF CAUSATION Discovery of microbiology - turningpoint GERM THEORY OF DISEASE Microbes as sole cause of disease 17 EARLIER THEORIES • Supernatural theory • Theory of Humors • Concept of contagion • Miasmatic theory • Theory of spontaneous generation Contagion theory Miasmatic theory
- 18. Limitations of Germ Theory • Why only some people suffer from the disease even after exposure • Why certain people carry pathogens but do not show manifestations of disease • Why a disease would be epidemic sometimes • It does not take into account the multi- factorial causation even in the diseases in which micro-organism is the “necessary cause”. 18
- 20. THE TETRAD OF EPIDEMIOLOGY 20 Mission of epidemiology – break one of the legs of triangle and disrupt the connection between these and thereby stopping outbreak.
- 21. MULTIFACTORIAL CAUSATION CONCEPT- disease is due to multiple factors and not a single one. PETTENKOFER OF MUNICH (1819-1901)-early proponent of this concept. “Germ theory of disease "or “single cause idea "in late 19th century overshadowed the multiple cause theory. 21
- 22. 22 DISEASE Other factors are responsible for disease….. Socioeconomic factors. Psychological factors.Cultural factors. Genetic factors.
- 23. 23 Poor nutrition Low immunity Concurrent disease Poverty Overcrowding malnutrition Mycobacterium tuberculi Eg: TB
- 24. ADVANCED MODEL OF THE TRIANGLE OF EPIDEMIOLOGY 24 Causative Factors Groups or populations and their characteristics Environment behaviour, culture physiological factors ecological elements TIME
- 25. WEB OF CAUSATION Suggested by- Mac Mahon and Pugh. “Web of causation” considers all the predisposing factors of any type and their complex interrelationship with each other. Removal or elimination of just one link or chain may be sufficient to control the disease, provided that link is sufficiently important in the pathogenetic process. 25
- 26. Web of causation for Myocardial Infarction 26
- 27. NATURAL HISTORY OF DISEASE 27 For successful prevention, control or eradication of disease in community one should know the natural history of the disease. Any disease has 2 phases namely:- 1. Pre-pathogenesis phase 2. Pathogenesis phase
- 28. PRE PATHOGENESIS PHASE • Disease agent has not entered man, but factors favouring disease exist in the environment. • What required is an interaction of these factors to initiate the disease process. Agent Host Environment 28
- 29. PATHOGENESIS PHASE Entry of disease agent in susceptible human host. Disease agent multiplies and induces tissue and physiological changes. Final outcome- recovery, disability or death. This phase may be modified by intervention measures such as immunization, chemotherapy 29
- 30. 30
- 31. AGENT FACTORS 31 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. 1. Biological Agents – Infectivity Pathogenicity Virulence 2. Nutrient 3. Physical 4. Chemical 5. Mechanical 6. Absence or insufficiency of a factor 7. Social
- 32. HOST FACTORS Human host - SOIL Disease agent – SEED Classified as Demographic characteristics Biological characteristics Social & Economic Lifestyle factors 32
- 33. ENVIRONMENTAL FACTORS All that which is external to the individual human host, living and non-living, and with which he is in constant interaction. -Macro-environment Physical Biological Psychosocial 33
- 34. RISK FACTORS Where the disease agent is not firmly established, the aetiology is generally discussed in terms of risk factors. The term risk factor is used by different authors with at least two meanings- An attribute or exposure that is significantly associated with development of disease. A determinant that can be modified by intervention, thereby reducing the possibility of occurrence of disease or other specified outcomes. 34
- 35. 35 Some risk factors can be modified while some cannot be modified
- 36. RISK GROUPS Approach developed and promoted by WHO is to identify precisely the “risk groups” in the population by certain defined criteria and direct appropriate action to them first. This is known as the risk approach. Has been summed up as “something for all, but more for those in need – in proportion to the need.” Helps to define priorities and points to those most in need of attention. 36
- 37. SPECTRUM OF DISEASE 37 Is a graphic representation of variations in the manifestations of disease. At one end are subclinical infections which are not ordinarily identified and at the other end are fatal illnesses. In the middle of the spectrum lie illnesses ranging in severity from mild to severe.
- 38. ICEBERG OF DISEASE Disease prevailing in the community may be compared to the iceberg. The tip of the iceberg represents the clinical cases prevailing in the community. The vast submerged portion of the iceberg represents the hidden mass of disease in the community that is latent, inapparent carriers. 38
- 39. 39 Symptomatic disease; clinical cases Latent, inapparent, presymptomatic and undiagnosed cases and carriers What the physician sees. What the physician does not see.
- 40. CONCEPTS OF 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. 40
- 41. Disease control includes… 41
- 42. DISEASE 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. DISEASE SURVEILLANCE: Defined as “the continuous scrutiny of the factors that determine the occurrence and distribution of disease and other conditions of ill health.” 42
- 43. What’s the difference?... Monitoring- requires careful planning, use of standardized procedures and methods of data collection and can then be carried over extended period of time by technicians and automated instrumentation. Surveillance requires professional analysis, sophisticated judgement of data leading to recommendation for control activities 43
- 44. CONCEPTS OF PREVENTION The goals of medicine are to Promote health, To preserve health, To restore health when it is impaired And to minimize suffering and distress. 44 These goals are embodied in the word "prevention"
- 45. The concept of prevention is best defined in the context of levels, traditionally called primary, secondary and tertiary prevention. A fourth level, called primordial prevention, was later added. 45
- 46. PRIMORDIAL PREVENTION DEFINITION 46 “It is the prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared.” INTERVENTION • The main intervention in primordial prevention is through individual and mass health education.
- 47. 2 approaches(WHO)- A)Mass strategy- Directed towards socio-economic, behavioural and lifestyle changes B) High-risk strategy Aims to bring preventive care to individuals at special risk 47
- 48. PRIMARY PREVENTION Signifies intervention in the pre-pathogenesis phase of disease or health problem. Relies on measures designed to promote health or to protect against specific disease agents or hazards Applied to prevention of chronic diseases like CHD, HT , cancer based on elimination or modification of risk factors of disease 48
- 49. SECONDARY PREVENTION Action which halts the progress of the disease at its incipient stage and prevents complication Early diagnosis and treatment- arrest the disease process and protect others in the community from acquiring the disease Health programs initiated by government are usually at this level. 49
- 50. TERTIARY PREVENTION Signifies intervention at late pathogenesis stage. All measures available to reduce or limit impairment and disabilities, minimise suffering caused by existing departure from good health and to promote patient adjustment to irremediable conditions. Through disability limitation and rehabilitation. 50
- 51. MODES OF INTERVENTION Intervention is any attempt to intervene or interrupt the usual sequence in the development of disease. Five modes of intervention corresponding to the natural history of any disease are: Health Promotion Specific Protection Early Diagnosis and Adequate Treatment Disability Limitation Rehabilitation 51
- 52. HEALTH PROMOTION It is the process of enabling people to increase control over diseases, and to improve their health. It is not directed against any particular disease but is intended to strengthen the host through a variety of approaches(interventions): 52
- 53. SPECIFIC PROTECTION Currently available interventions 1. Immunization 2. Use of specific nutrients 3. Chemoprophylaxis 4. Protection against occupational hazards 5. Protection against accidents 6. Protection from carcinogens 7. Avoidance of allergens 53
- 54. EARLY DIAGNOSIS AND TREATMENT WHO defined early detection of health impairment as “the detection of disturbances of homeostatic and compensatory mechanism while biochemical, morphological, and functional changes are still reversible.” Ex – essential hypertension, cancer of cervix and breast cancer 54
- 55. DISABILITY LIMITATION Objective- is to prevent or halt the transition of the disease process from impairment to handicap. Sequence of events leading to disability & handicap: Disease → Impairment → Disability→ Handicap. WHO defined these terms- Impairment: Loss or abnormality of psychological, physiological/anatomical structure or function. Disability: Any restriction or lack of ability to perform an activity in a manner considered normal for one’s age, sex, etc. Handicap: Any disadvantage that prevents one from fulfilling his role considered normal. 55
- 56. “Combined and coordinated use of medical, social, educational and vocational measures for training and retraining the individual to the highest possible level of functional ability”. Areas of concern in rehabilitation: medical, vocational, social, psychological. 56REHABILITATION
- 57. CHANGING PATTERN OF DISEASE Although diseases have not changed significantly through human history, their patterns have. Every decade produces its own patterns of disease. 57
- 58. 58
- 59. DISEASE CLASSIFICATION A system of classification was needed whereby diseases could be grouped according to certain common characteristics , that would facilitate the statistical study of disease phenomena. International classification of disease (ICD) by WHO - accepted for national and international use. Revised once in 10 years. 59
- 60. ICD-10 ARRANGED IN 21 DIFFERENT CHAPTERS 60
- 61. CONCLUSION Understanding disease pathology is the first step towards formulating preventive measures. As a dentist or public health worker it is our primary responsibility for the prevention of diseases in community as well as individual. 61
- 62. Park, Park’s Textbook of Preventive & Social Medicine, 23rd Edition, Jabalpur: Banarsidas Bhanot,2015. Soben Peter. Essentials of Public Health Dentistry. 4th ed. New Delhi: Arya Publising House; 2013. Epidemiology, L. Gordis, Fourth ed, 2009, Saunders Gupta MC, Mahajan BK. Textbook of preventive and social medicine 3rd Edition, Jaypee publishers,2003 62REFERENCES
- 63. Hiremath S.S. Textbook of preventive and community dentistry. 3rd ed. Elsevier publishers, New Delhi; 2016. www.who.int www.oraldiseaserisk.com www.googleimages.com 63
- 64. PREVIOUS YEAR QUESTIONS Epidemiological triad. [10 marks] RGUHS M.D.S. DEGREE EXAMINATION Concepts of disease. [10 marks] RGUHS M.D.S. DEGREE EXAMINATION 2004. Risk factors and risk groups. [7 marks] RGUHS M.D.S. DEGREE EXAMINATION May 2012. 64
- 65. Thank You!
Notes de l'éditeur
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- Spontaneous generation or anomalous generation is an obsolete body of thought on the ordinary formation of living organisms without descent from similar organisms. Typically, the idea was that certain forms such as fleas could arise from inanimate matter such as dust, or that maggots could arise from dead flesh. The miasma theory (also called the miasmatic theory) held that diseases such as cholera, chlamydia, or the Black Death were caused by a miasma (μίασμα, ancient Greek: "pollution"), a noxious form of "bad air", also known as "night air". Simple Definition of contagion. : the process by which a disease is passed from one person or animal to another by touching. : a disease that can be passed from one person or animal to another by touching : a contagious disease. Upon the time of louis pasteur concepts of disease causation - supernatural theory, theory of humors, concept of contagion, miasmatic theory Turning point discovery of microbiology. Drawback of germ theory – not every one exposed to tb develops tb.disease is rarely caused by a single agent rather depends on no of factors.
- This demanded a broader concept of disease causation that synthesized the basic factors of agent, host and environment.
- host- man or animal in which agent harbours Agent- cause of disease Environment- surroundings which allow disease transmission Time- incubation period, life expectancy of host, duration of illness.
- Tuberculosis is not merely due to tubercle bacilli; factors such as poverty, overcrowding & malnutrition contribute to its occurrence.
- This model is ideally suited for the study of chronic diseases where disease agent is often not known, but is the outcome of interaction of multiple factors.
- Predisposing factors of any type and their complex interrelationship with each other.
- Each disease has its own unique natural history which is not necessarily same for in all individuals. What the physician sees in his clinic is just an episode .how disease evolves over time assesed by cohort studies. Helps the epidemiologists to fill the gaps.
- Preliminary to onset of disease. Man in the midst of disease.
- Biological agents- living agents ex virus fungi bacteria Infectivity – the ability of an infectious agent to invade and multiply in a host. Nutritive – proteins fats carbohydrates Pathogenicity – ability to induce clinically apparent illness Virulence- proportion of clinical cases resulting in severe clinical manifestations. (case fatality rate)
- Demographic characteristics - age, sex, ethnicity Biologic- genetic factors, biochemical levels of the blood enzymes Socioeconomis – socio economic status, education, occupation, stress, marital status Lifestyle –personality traits, living habits, nutrition, exercise alcohol, drugs etc
- Diseases where agent is not identified- coronary heart disease, cancer , peptic ulcer, mental illness.
- Modern epidemiology is concerned with the identification of risk factors nd high risk groups in population. Define prioritis and point to those most in need of attention.
- Spectrum of leprosy…. Infectious diseases its called gradient of infection.
- The Iceberg Theory of Disease is metaphor portraying the idea that clinicians only see a minority of cases of any given disease (tip of the iceberg); for every case that comes to a clinician, there are likely to be many more people with pre-clinical disease in the community (vast submerged part)
- Prevention is to stop disease from happening. While control is to stop something that has already happened.
- Primary prevention can be defined as the action taken prior to the onset of disease, which removes the possibility that the disease will ever occur. Of the three levels, the target population that will be the focus of primary prevention will be relatively larger than the populations in other levels. Note that many of these activities will overlap with health promotion activities. GOAL: Preventing new cases of a disease (reducing incidence of disease) is the ultimate goal of primary prevention. RATIONALE: Reducing exposure risk will reduce incidence of disease. This may involve removing the exposure risk so it is not encountered. EXAMPLE: Chlorinating the city water supply to reduce the number of enteric pathogens present in the drinking water; spraying for mosquitoes to reduce risk of exposure to malarial plasmodia; using netting over bed to reduce nocturnal mosquito bites. May involve removing population so it is not in contact with risk. EXAMPLE: Forbidding public access to sewage treatment water and area; restricting travel to areas where malaria is endemic. OTHER PART OF RATIONALE: Increasing resistance to disease if exposed will also reduce incidence of disease If exposure risk cannot be entirely eliminated, may seek ways to strengthen natural defenses. EXAMPLE: Vaccination to promote the development of antibodies so body can prevent the development of disease if it is exposed. TARGET POPULATION: This will change depending on disease. TYPICAL ACTIVITIES: Keeping the two rationales in mind, activities will focus on efforts to remove or reduce source of risk as well as prepare the target population to avoid and resist its effects. Remove source of risk – for malaria, which is transmitted via a mosquito vector, this may include draining standing water where mosquitoes may breed. Educate about risk/change behaviors – provide exposure risk information along with tips for how to reduce exposures. Netting for bedding, staying indoors during morning and evening hours when mosquitoes are most active, and using a DEET mosquito repellant when outdoors. Other general tips for contagious diseases include handwashing and keeping hands away from eyes or mouth. Improve general health – this is where disease prevention and health promotion overlap. In general, a healthier person is better able to mount an immune response and avoid disease. Should the person become exposed and sick, they will often have a better chance of recovering. OUTCOME MEASURE: Number of exposures to a causative agent or risk factor Final outcome would be number of new cases of disease (incidence) Be sure students understand what incidence (incidence rate) means. Incidence = the number of new cases in a given time period Incidence rate = ratio of new cases to total population at risk for a given period of time. Allows comparison of incidence to other diseases or other populations.
- GOAL: Reducing the severity of a disease (reducing morbidity) and new cases (incidence) are the ultimate goals of secondary prevention. This may apply to the individual case (reduce severity of symptoms or duration of illness) and the community (reduce severity of outbreak – or said another way – reduce the spread of the disease and shorten the length of time the outbreak exists). RATIONALE: Early detection of a disease-causing exposure or identifying a disease in its early stages can lead to early treatment to either stop the progression of the disease or reduce its severity which will reduce complications. Identifying those who are sick can also aid in reducing the spread of the disease to others in the community. EXAMPLE: Detecting exposure to lead through blood tests can lead to the removal of the lead source. Screening interviews can be used to identify who has been in close contact with a person diagnosed with an infectious disease and the timely use of post-exposure prophylaxis to “nip” the possible infection in the bud. For chronic diseases like diabetes, early detection via A1c levels can lead to earlier control of blood sugar and a reduction in both short and long term complications of the disease. TARGET POPULATION: This now becomes the individuals who were in the “risk of exposure” or “risk of disease” group who have been exposed or have early disease. So it is a subset of the primary prevention population for that specific disease. TYPICAL ACTIVITIES: Like primary prevention, secondary prevention has two key types of activities that help you identify it. SCREENING to detect exposure or early disease is one; the other is EARLY TREATMENT to either prevent or reverse the disease process entirely or reduce the severity of the illness. Another type of early interventions at the population level would be quarantining those who have been exposed so they are not in contact with others; for those with early symptoms of the illness, isolation would be used to minimize contact with healthy folks. EXAMPLES: For exposure to a toxic chemical, secondary prevention would use decontamination to remove exposure before it caused harm and/or an antidote to counteract the effects of the toxin. An exposure to an organophosphate pesticide would be treated in both of these ways. If decontamination and the administration of atropine did not completely counteract the effects of the poisoning, then the severity would probably be reduced. At the population level, interventions may involve preventing people from entering a contaminated area and offering methods for removing contaminants. For an infectious disease like Varicella (chickenpox), screening interviews can be used to determine if a person has likely been exposed. Questions like did they share a drinking glass or kiss? Were they close together for four or more hours? Did they care for someone who had chickenpox, or did they already have immunity to chickenpox through a vaccine or prior illness can be used to identify good candidates for vaccination? Another group would be those who are just beginning to show symptoms – they may be a good candidate for early treatment with an antiviral. At the population level, would encourage sick folks to stay home (self-imposed isolation) and their caregivers to seek vaccination if not already immune. OUTCOME MEASURE: Number of cases of disease (compare to number of exposures in primary level) Be sure students understand what incidence (incidence rate) means. Incidence = the number of new cases in a given time period Incidence rate = ratio of new cases to total population at risk for a given period of time. Allows comparison of incidence to other diseases or other populations.
- GOAL: Reducing the risk of disease-related premature mortality or long-term morbidity and increasing likelihood of returning to a state of health. RATIONALE: Once disease occurs, need to work to cure patient and avoid long-term illness or complications. Doing so will reduce mortality and morbidity rates and reduce prevalence rates. EXAMPLE: Lead poisoning that has resulted in symptoms now requires treatment to address lead toxicity illness and end organ complications. For chronic diseases like diabetes, tertiary prevention will focus on controlling the disease so premature death and complications are avoided. For an infectious disease, the tertiary levels of prevention will use antibiotics or anti-microorganism (viral, protozoan, fungal, etc) medications if available to directly treat infection causing disease and supportive care to allow the disease to run its course while reducing risks of complications created by the infective agent or its by-products (e.g., shock due to toxins released during a gram negative infection). TARGET POPULATION: This now becomes the individuals who develop the illness. It is a subset of the population identified for secondary prevention. TYPICAL ACTIVITIES: For individuals, these activities are best described as clinical or THERAPEUTIC interventions – something that should be/will be very familiar to pharmacy students. In addition to treatment, there are REHABILITATION activities that are used for individuals who have permanent or long-term disabilities due to the disease. The goal of rehabilitation is to resume as normal a lifestyle as the person had prior to the disease. At the population level, tertiary activities may include ensuring individuals has access to care sites or professionals, research to find more effective treatments, and support groups for recovering individuals. EXAMPLES: Using the toxic exposure example, tertiary prevention would concentrate on supportive care if antidotes were not available or not effective. If the exposure were a venomous snake bite that was not promptly treated with anti-venom, it is possible that the injured person may have surgical intervention to reduce pressure building up in the muscle bundles (fasciitis) or even amputation if damage to a limb is too extensive. Post surgical rehabilitation would be used to help the person resume many of their usual activities. At the population level, ensuring access to anti-venom may be important – because it is so expensive, hospitals For an infectious disease like varicella (chickenpox), the goal of tertiary prevention will be recovery from the immediate infection without the development of complications. One long-term complication of a varicella infection called shingles would best be addressed through primary prevent efforts involving vaccination of older adults who are at risk of shingles. If this is confusing, consider the development of shingles as a separate disease from chicken pox and it may be easier to think about primary prevention. OUTCOME MEASURE: Prevalence rates for disease (cures should lower it) Mortality rates Morbidity rates
- Essential hypertension, cancer cervix
- Table- comparison of leading causes of death worldwide over past decade
- Wide variation among countries in criteria and standars adopted for diagnosis of diseases making it difficult to compare national statistics.
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