10/09/2014

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NATURAL HISTORY AND LEVELS
OF PREVENTION OF A
COMMUNICABLE DISEASE IN A
HUMAN POPULATION

By Dr. F.D.E Mtango

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Introduction
ALL DISEASES WHETHER COMMUNICABLE
OR NON-COMMUNICABLE HAVE A NATURAL
HISTORY. TODAY WE SHALL CONSIDER ONLY
THE NATURAL HISTORY OF A
COMMUNICABLE DISEASE.

HOWEVER, OTHER PROBLEMS OTHER THAN
DISEASES, EG. POVERTY, SLAVERY,
WITCHCRAFT, ETC, ALSO HAVE THEIR
NATURAL HISTORIES.


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Introduction 2
IN A SENSE, WE CAN CONSIDER EVERYTHING
IN THE WORLD AS NATURAL, IF IT IS NOT
SUPERNATURAL, IN ONE SENSE, AND IN
ANOTHER SENCE, IF THERE IS NO
INTERVENTION BY ANY HUMAN ACTION.

WE SHALL CONSIDER A DISEASE TO BE THE
EQUIVALENT OF A PATHOLOGY (OR
DEVIATION FROM NORMAL HUMAN
BIOLOGY). HISTORY DENOTES JUST A
PROCESS OF TIME

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DEFINITION

NATURAL HISTORY OF A
DISEASE IS THE COURSE OF A
DISEASE OVER TIME, WHEN
UNAFFECTED BY ANY HUMAN
INTERVENTION (PREVENTION,
TREATMENT OR
REHABILITATION)
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REASONS FOR STUDYING
THE NATURAL HISTORY
1. TO FORMULATE HYPOSESES FOR
DETERMINANTS OF DISEASES,
INCLUDING PREVENTIVE MEASURES
AND CONTROL STRATEGIES
2. EVALUATION OF PREVENTIVE AND
CONTROL STRATEGIES
3. PREDICTION OF sequelae (outcome)
4. TO GIVE THE FULL PICTURE OF THE
DISEASE AND ALLOW VARIOUS LEVELS
OF PREVENTION
5. TO STUDY THE INTERACTIONS OF
DISEASES





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STAGES IN THE NATURAL HISTORY OF A DISEASE
The following are the stages of the natural
history of an infectious disease:
1) PRE-PATHOGENESIS OR
PRE-DISEASE STAGE

2) PATHOGENESIS OR DISEASE STAGE

3) POST-PATHOGENESIS OR POST
DISEASE STAGE
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STAGE OF PRE-PATHOGENESIS
This is a period before onset of disease in the
human population, but the factors responsible or
that favour its occurrence already exist in that
population (the ground work has been laid down)
. In this period there is interaction between those
factors (host, agent and environment factors).
This interaction or interplay ultimately produce
an opportunity for the start of disease or infection
in case of an infectious disease (disease stimulus)
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STAGE OF PRE-PATHOGENESIS 2
Remember that as epidemiologists we
study the distribution of disease in human
populations rather than in an individual.
This is different from clinicians, who
examine diseases in individuals, hence we
are looking at the pre-pathogenesis of a
disease in a human population

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FACTORS RESPONSIBLE FOR
PRE-PATHOGENESIS
Host factors: a host is an organism capable
of being infected by an agent
Agent Factors: Agent refers to an
etiological factor, which is necessary for
bringing about a particular disease in a
susceptible host.
.
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FACTORS RESPONSIBLE FOR
PRE-PATHOGENESIS 2
Risk factors: These are factors whose
presence is associated with an increased
probability for the disease to develop.
Risk factors may be fixed, e.g. age, sex,
race or modifiable, e.g. smoking habit,
alcoholism and a high level of serum
cholesterol
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Agent factors
Agents: Plasmodium, Yesinia pestis,
Microbacterium tuberculosis
Agent factors:
Survival in external environment,
Infectivity, Pathogenicity,Virulence,
Antigenicity

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Agent factors 2
Kochs isolation of the anthrax bacilus
in 1870 was a wonderful discovery,
because this was the first
demonstration of a causative agent of
an infectious disease beyond, a
reasonable doubt

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Kochs postulates
1. The microorganism must be routinely
isolated from the patients with a
particular disease
2. It must be grown in pure culture
3. When the pure culture is inoculated to a
new host it must produce the same
disease
4. The same microorganism must be
isolated from the new host
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Host factors:
Age
Sex
Social class
Personality
Genetic factors
Education
Marital status
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Physical Environmental factors:
Climate
Altitude
Temperature
Presence and density of population of
vectors
Environmental sanitation
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Social Environmental factors:
Culture
Economic conditions, poverty
Health services
Social services

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Stage of Pathogenesis
This is the process between onset of disease
stimuli (or interaction between host and
agent and environmental factors) and the
development of discernible lesions and
recovery or progression of disease process
to the forrmation of disability or death.
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Stage of Pathogenesis 2
This disease process can be terminated,
shortened or made more tolerable
through human interventions, in
terms of treatment (secondary
prevention) or rehabilitation (tertiary
prevention).


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Stage of Post-pathogenesis:
This is the stage where the agent (or
necessary factor) has already been
removed from the affected
populations (patients), but the effects
of the disease are persisting in the
form of deformity and or disability
(or sequelae of the disease).

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Stage of Post-pathogenesis 2
A new disease may be a post-
pathogenesis of another disease, e.g.
rheumatic fever is a post-pathogenesis
of beta hemolytic streptoccoci sore
throat

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Reasons for studying the natural
history of diseases
1. Identification of preventive measures: By
enabling us to list the factors (agents or
risk factors) which predispose and or
cause a given disease, we can prevent
the disease.
2. Identification of control strategies
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Reasons for studying the natural
history of diseases 2
3. Prediction of prognosis, i.e. to estimate the
probability that a patient will be cured or
die of the disease
4. Evaluation of preventive measures, for
example if we know untreated 50% of
patients would die, whereas if treated
only 10%, then we have a good basis for
adapting the treatment

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In a narrow sense prevention means
preventing the development of a disease
before it occurs. However, in
epidemiology the term prevention includes
measures that interrupt or slow the
progression of the disease. Hence 4 levels
of prevention have been identified in
epidemiology as seen in the following
slides:
PREVENTION
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LEVELS OF PREVENTION
1. PRIMORDIAL PREVENTION

2. PRIMARY PREVENTION

3. SECONDARY PREVENTION

4. TERTIARY PREVENTION
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PRIMORDIAL PREVENTION
This is the first level of prevention,
which is the prevention of risk factors
or prevention of the the interaction
between host and environmental
factors, so that disease may not occur.

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PRIMORDIAL PREVENTION 2
The country should anticipate the
occurrence of disease, before it occurs
and modify the conditions responsible
for its occurrence , bearing the
experience of other countries. The
Unga problem is an example of a
problem, which should have been
avoided, before it started, in this
country.
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PRIMARY PREVENTION
This is the second level of prevention.
This is the prevention of healthy
people from becoming ill, e.g. through
immunization, wearing of shoes to
prevent hookworm, adequate intake of
proteins and vitamins to prevent
malnutrition or use mosquito nets to
prevent malaria.
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PRIMARY PREVENTION 2
In primary prevention the population
can also be educated to avoid
dangerous habits, such as the use of
bushes for defecation, to prevent
diarrheal diseases cessation of
smoking to prevent lung cancer. In
this way, the disease incidence is
lowered or the disease is controlled.

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SECONDARY PREVENTION:
This refers to detection of people ,
who already have a given disease, as
early as possible, in order to stop the
disease from developing further (early
diagnosis and early treatment of
disease) to increase recovery rate and
reduce disability and or mortality.

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SECONDARY PREVENTION 2
Screening for early diagnosis and
treatment can be done for sub-clinical
disease using laboratory tests. Clinical
examination can also be done to
discover the early manifestation of
disease, which are easier to reverse.
Treatment can be either by drugs or
by lifestyle modification or by natural
remedies, such as water.

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TERTIARY PREVENTION:
This is prevention of further disability
and or prevention and postponement
of death due to disability or secondary
diseases
It may concern patients who have
been cured of the primary disease but
have a permanent disability, e.g post
polio paralysis or post trachoma
blindness. Such patients needs
rehabilitation.
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TERTIARY PREVENTION 2
The word rehabilitation comes from
the word habilis, latin for hand. That
is giving a new hand to one who has
lost hands is the literal meaning of
rehabilitation.
Palliative care is an example of
tertiary prevention for people who
cannot be cured, e.g AIDS and cancer
cases
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Practical
In this practical the class shall be divided
into two groups. Each group shall outline
the natural history and levels of prevention
of a disease. Groups shall do this
assignment and present to the class and
hand me also a written version for grading:

For the this practical , the groups shall
develop the natural history and levels of
prevention of cholera and tuberculosis in
Tanzania. Copies of notes from the
Wikepedia are given to assist the groups
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Thank you for your attention
and participation!!!