ICEBERG THEORY

AND
EPIDEMIOLOGICAL THEORY

BY:
NISHA DWA
ROLL NO. 3
MN 1ST YEAR
ICEBERG THEORY
• The pattern of disease encountered in a hospital is
quite different from that in a community.
• In the community a far larger proportion of disease
(e.g. diabetes, hypertension) is hidden from the view
of the general public or physician.
• A concept closely related to the spectrum of disease is
the concept of the iceberg phenomenon of disease.
• According to this concept, disease in a community
may be compared with an iceberg.
• The floating tip of the iceberg represents what the
physician sees in the community, i.e., clinical cases.
• The vast submerged portion of the iceberg represents
the hidden mass of disease, i.e., latent, in apparent,
pre-symptomatic and undiagnosed cases and carriers
in the community.
• The “waterline” represents the demarcation between
apparent and in apparent disease.
• In some diseases (e.g., hypertension, diabetes, anaemia,
malnutrition, mental illness) the unknown morbidity (i.e., the
submerged portion of the iceberg) far exceeds the known
morbidity.
• The hidden part of the iceberg thus constitutes an
important, undiagnosed reservoir of infection or disease in
the community, and its detection and control is a challenge
to modern techniques in preventive medicine.
• One of the major deterrents in the study of chronic diseases
of unknown aetiology is the absence of methods to detect
the subclinical state – the bottom of the iceberg.
1. Diagnosed diseases:
• May include controlled and uncontrolled diseases.
• These are diseases which are easily and commonly identified
diseases.
• Diseases which are symptomatic.

2. Undiagnosed diseases:
• Unidentified cases of disease which are not treated due to its
unknown nature.
3. Wrongly diagnosed disease:
• An inaccurate assessment of a patient’s condition that sometimes
lead to wrong treatment.

4. Risk Factors for disease:

• People that fall under this category have a high chance of acquiring a
said disease.
5. Free of risk factors:
• These are people who have low chances of acquiring a
disease.
• People who are considered completely healthy.
Example: Hypertension

• Diagnosed diseases: Hypertensive patients who are given

medical attention.
• Undiagnosed or wrongly diagnosed diseases: People who
are not aware that they are hypertensive; patients who are
said to be normotensive but are actually hypertensive.
• Risk factors for disease: People with old age;
overweight/obese people; people with unhealthy lifestyle.
• Free of risk factors: Young people with healthy lifestyle.
EPIDEMIOLOGICAL THEORY
• Germ theory of disease
• Epidemiological triad
• Multifactorial causation
• Web of causation
• Natural history of disease
GERM THEORY OF DISEASE
• Several theories were advanced from time to time to explain
disease causation.
• Supernatural theory of disease, the theory of humors by
Greek and Indians, the theory of contagion, the miasmatic
theory which attributed disease to noxious air and vapors,
the theory of spontaneous generation, etc.
• 1860 – The French bacteriologist Louis Pasteur (1822
– 1895) demonstrated the presence of bacteria in air.
• He disproved the theory of “spontaneous generation”.
• 1873 – Pasteur advanced the “germ theory of
disease”.
• 1877 – Robert Koch (1843 – 1910) showed that
anthrax was caused by a bacteria.
• These discoveries confirmed the germ theory of
disease.
• Microbe after microbe was discovered in quick
succession – gonococcus (1847), typhoid bacillus &
pneumococcus (1880), tubercle bacillus (1882),
cholera vibrio (1883), etc.
• All attention was focused on microbes and their role
in disease causation.
• The germ theory of disease came to the forefront,
supplanting the earlier theories of disease causation.
• The germ theory of disease gained momentum during
the 19th and the early part of 20th century.
• Germ theory states that many diseases are caused by
the presence and actions of specific micro-organisms
within the body.
• The emphasis had shifted from empirical causes (e.g.,
bad air) to microbes as the sole cause of disease.
• The concept of cause embodied in the germ theory of disease is
generally referred to as a one-to-one relationship between causal
agent and disease. The disease model accordingly is:

Disease agent Man Disease

• The germ theory of disease, though it was a revolutionary
concept, led many epidemiologists to take one-sided view of
disease causation.
• That is, they could not think beyond the germ theory of
disease.
• It is now recognized that a disease is rarely caused by a single
agent alone, but rather depends upon a number of factors
which contribute to its occurrence.
• Therefore, modern medicine has moved away from the strict
adherence to the germ theory of disease.
EPIDEMIOLOGICAL TRIAD
• There are other factors relating to the host and
environment which are equally important to
determine whether or not disease will occur in the
exposed host.
• This demanded a broader concept of disease
causation that synthesized the basic factors of agent,
host and environment.
• The above model – agent, host and environment – has
been in use for many years.
• It helped epidemiologists to focus on different classes
of factors, especially with regard to infectious
diseases.
• The traditional triangle of epidemiology is based on
the communicable disease model and is useful in
showing the interaction and interdependence of
agent, host, environment, and time as used in the
investigation of diseases and epidemics.
Agent:
• Agents of infectious diseases include bacteria, viruses,
parasites, fungi, and molds.
• With regard to non-infectious disease, disability, injury
or death, agents can include chemicals from dietary
foods, tobacco smoke, solvents, radiation or heat,
nutritional deficiencies, or other substances, such as
poison.
• One or several agents may contribute to an illness.
Host:
• A host offers subsistence and lodging for a pathogen and
may or may not develop the disease.
• The level of immunity, genetic makeup, level of exposure,
state of health, and overall fitness of the host can determine
the effect a disease organism will have on it.
• The makeup of the host and the ability of the pathogen to
accept the new environment can also be a determining
factor because some pathogens thrive only under limited
ideal conditions.
• For example, many infectious disease agents can exist only in
a limited temperature range.
Environment:
• Biological aspects as well as social, cultural, and
physical aspects of the environment.
• The surroundings in which a pathogen lives and the
effect the surroundings have on it are a part of the
environment.
• Environment can be within a host or external to it in
the community.
Time:
• Time includes severity of illness in relation to how
long a person is infected or until the condition causes
death or passes the threshold of danger towards
recovery.
• Delays in time from infection to when symptoms
develop, duration of illness, and threshold of an
epidemic in a population are time elements with
which the epidemiologist is concerned.
The primary mission of epidemiology is to provide
information that results in breaking one of the legs of
the triangle, thereby disrupting the connection among
environment, host, and agent, and stopping the
outbreak.
MULTIFACTORIAL CAUSATION
• Pettenkofer of Munich (1819 – 1901) was an early
proponent of the concept that disease is due to
multiple factors.
• The “germ-theory of disease” or “single cause idea” in
the late 19th century over-shadowed the multiple
cause theory.
• As a result of advances in public health, chemotherapy,
antibiotics and vector control, communicable diseases began
to decline.
• But was replaced by new types of diseases, the so-called
modern diseases of civilization.
• E.g., Lung cancer, coronary heart disease, chronic bronchitis,
mental illness, etc.
• These diseases could not be explained on the basis of the
germ theory of disease nor could they be prevented by the
traditional methods of isolation, immunization or
improvements in sanitation.
• The realization began to dawn that the “single cause idea”
was an oversimplification and that there are other factors in
the aetiology of diseases – social, economic, cultural, genetic
and psychological which are equally important.
• It is now known that diseases such as coronary heart
disease and cancer are due to multiple factors.
• For example, excess of fat intake, smoking, lack of
physical exercise and obesity are all involved in the
pathogenesis of coronary heart disease.
• Most of these factors are linked to lifestyle and
human behavior.
• Medical men are looking “beyond the germ theory of
disease into the total life situation of the patient and
the community in search of multiple (or risk) factors
of disease.
• The figure below presents an adapted and advanced
model of the triangle of epidemiology.
 Causative factors

Time

Groups or populations Environment behavior,

and their culture physiological factors
characteristics ecological elements
• The purpose of knowing the multiple factors of
disease is to quantify and arrange them in priority
sequence (prioritization) for modification or
amelioration to prevent or control disease.
• The multifactorial concept offers multiple approaches
for the prevention/control of disease.
WEB OF CAUSATION
• This model of disease causation was suggested by
MacMohan and Pugh in their book: “Epidemiologic
Principles and Methods”.
• 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 interrelationship
with each other.
• The basic tenet of epidemiology is to study the
clusters of causes and combinations of effects and
how they relate to each other.
 Changes in lifestyle Stress

Abundance of food Lack of physical Smoking

exercise Emotional
disturbance
Ageing and other
factors

Obesity Hypertension
Increased catacholamines
thrombotic tendency
Hyperlipidaemia

Coronary occlusion
Changes in walls of arteries
Coronary atherosclerosis

Myocardial ischaemia

Myocardial infarction

Fig: Web of causation of myocardial infarction

• It can be visualized that the causal web provides a
model which shows a variety of possible interventions
that could be taken which might reduce the
occurrence of myocardial infarction.
• The web of causation does not imply that the disease
cannot be controlled unless all the multiple causes or
chains of causation or at least a number of them are
appropriately controlled or removed.
• Sometimes removal or elimination of just only one
link or chain may be sufficient to control disease,
provided that link is sufficiently important in the
pathogenetic process. In a multifactorial event,
therefore, individual factors are by no means all of
equal weight.
• The relative importance of these factors may be
expressed in terms of “relative risk”.
NATURAL HISTORY OF DISEASE
• The term natural history of disease is a key concept in
epidemiology.
• It signifies the way in which a disease evolves over time from
the earliest stage of its prepathogenesis phase to its
termination as recovery, disability or death, in the absence of
treatment or prevention.
• Each disease has its own unique natural history, which is not
necessarily the same in all individuals, so much so, any
general formulation of the natural history of disease is
necessarily arbitrary.
• What the physician sees in the hospital is just an
“episode” in the natural history of disease.
• The epidemiologist, by studying the natural history of
disease in the community setting, is in a unique
position to fill the gaps in our knowledge about the
natural history of disease.
Schematic diagram of the natural history of disease:
• It is a necessary framework to understand the
pathogenetic chain of events for a particular disease,
and for the application of preventive measures.
• It is customary to describe the natural history of
disease as consisting of two phases: prepathogenesis
(i.e., the process in the environment) and
pathogenesis (i.e., the process in man).
 
Prepathogenesis phase:
• The period preliminary to the onset of disease in man.
• The disease agent has not yet entered man, but the factors
which favour its interaction with the human host are already
existing in the environment.
• This situation is frequently referred to as “man in the midst
of disease” or “man exposed to the risk of disease”.
• Potentially we are all in the prepathogenesis phase of many
diseases, both communicable and non-communicable.
• The causative factors of disease may be classified as
AGENT, HOST and ENVIRONMENT.
• The mere presence of agent, host and favourable
environmental factors in the prepathogenesis period
is not sufficient to start the disease in man.
• What is required is an interaction of these three
factors to initiate the disease process in man.
• The agent, host and environment operating in
combination determine not only the onset of disease
which may range from a single case to epidemics but
also the distribution of disease in the community.
Pathogenesis phase:
• The pathogenesis phase begins with the entry of the
disease “agent” in the susceptible human host.
• In case of infectious diseases:
The further events in the pathogenesis phase are
clear-cut.
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.
The final outcome of the disease may be recovery,
disability or death.
The pathogenesis phase may be modified by
intervention measures such as immunization and
chemotherapy.
It is useful to remember at this stage that the host’s
reaction to infection with a disease agent is not
predictable.
The infection may be clinical or subclinical; typical or
atypical or the host may become a carrier with or
without having developed clinical disease as in the
case of diphtheria and hepatitis B.
• In case of chronic diseases:
The early pathogenesis phase is less dramatic.
This phase in chronic diseases is referred to as
presymptomatic phase.
During the presymptomatic stage, there is no
manifestation of disease.
The pathological changes are essentially below the
level of the “clinical horizon”.
• The clinical stage begins when recognizable signs or
symptoms appear.
• By the time signs and symptoms appear, the disease
phase is already well advanced into the late
pathogenesis phase.
• In many chronic diseases, the agent-host-
environmental interactions are not yet well
understood.
Agent factors
• First link in the chain of disease transmission.
• The disease “agent” is defined as a 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.
• A disease may have a single agent, a number of independent
alternative agents or a complex of two or more factors
whose combined presence is essential for the development
of the disease.
May be classified broadly into the following
groups:
1. Biological agents
Living agents
Viruses, rickettsiae, fungi, bacteria, protozoa and
metazoan.
These agents exhibit certain “host-related” biological
properties such as:
(i) Infectivity: this is the ability of an infectious agent to
invade and multiply (produce infection) in a host;
(ii) Pathogenicity: this is the ability to induce clinically
apparent illness, and
(iii)Virulence: this is defined as the proportion of
clinical cases resulting in severe clinical
manifestations (including sequelae).
2. Nutrient agents
Proteins, fats, carbohydrates, vitamins, minerals and water.
Any excess or deficiency of the intake of nutritive elements
may result in nutritional disorders.
Protein energy malnutrition (PEM), anaemia, goiter, obesity
and vitamin deficiencies are some of the current nutritional
problems in many countries.
3. Physical agents
Exposure to excessive heat, cold, humidity, pressure,
radiation, electricity, sound, etc. may result in illness.

4. Chemical agents
Endogenous: Some of the chemicals may be produced in the
body as a result of derangement of function, e.g., urea
(ureamia), serum bilirubin (jaundice), ketones (ketosis), uric
acid (gout), calcium carbonate (kidney stones), etc.
Exogenous: Agents arising outside of human host, e.g.,
allergens, metals, fumes, dust, gases, insecticides, etc. These
may be acquired by inhalation, ingestion or inoculation.
5. Mechanical agents
Exposure to chronic friction and other mechanical forces
may result in crushing, tearing, sprains, dislocations and even
death.

6. Absence or insufficiency or excess of a factor necessary to

health
These may be
(i) Chemical factors: e.g., hormones (insulin, oestrogens,
enzymes)
(ii) Nutrient factors
(iii) Lack of structure: e.g., thymus
(iv) Lack of part of structure: e.g., cardiac defects
(v) Chromosomal factors: e.g., mongolism, turner’s syndrome,
and
(vi)Immunological factors: e.g., agammaglobulinaemia.
7. Social agents
It is also necessary to consider social agents of
disease.
These are poverty, smoking, abuse of drugs and
alcohol, unhealthy lifestyles, social isolation, maternal
deprivation, etc.
Host factor
• Human host – soil
• Disease agent – seed
• The host factors may be classified as:
(i) Demographic characteristics such as age, sex, ethnicity;
(ii) Biological characteristics such as genetic factors;
biochemical levels of the blood (e.g., cholesterol); blood
groups and enzymes; cellular constituents of the blood;
immunological factors; and physiological function of
different organ systems of the body (e.g., blood pressure,
forced expiratory ventilation, etc.)
(iii) Social and economic characteristics such as socio-
economic status, education, occupation, stress, marital status,
housing, etc. and
(iv) Lifestyle factors such as personality traits, living habits,
nutrition, physical exercise, use of alcohol, drugs and smoking,
behavioral patterns, etc.

• The association of a particular disease with a specific set of

host factors frequently provides as insight into the cause of
disease.
Environmental factors
• The external or macro-environment is defined as “all that
which is external to the individual human host, living and
non-living, and with which he is in constant interaction”.
• This includes all of man’s external surroundings such as air,
water, food, housing, etc.
• The environment of man has been divided into three
components – physical, biological and psychosocial.
1. Physical environment
Non-living things and physical factors
Air, water, soil, housing, climate, geography, heat, light,
noise, debris, radiation, etc.
Man has altered practically everything in his physical
environment to his advantage.
In doing so, he has created for himself a host of new health
problems such as air pollution, water pollution, noise
pollution, urbanization, radiation hazards, etc.
The increasing use of electrical and electronic
devices, including the rapid growth of
telecommunication system (e.g., satellite systems),
radio broadcasting, television transmitters and radar
installations have increased the possibility of human
exposure to electromagnetic energy.
2. Biological environment
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.
These are constantly working for their survival, and in this
process, some of them act as disease-producing agents,
reservoirs of infection, intermediate hosts and vectors of
disease.
3. Psychosocial environment
It includes a complex of psychosocial factors which are
defined as “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”.
They include cultural values, customs, habits, beliefs,
attitudes, morals, religion, education, lifestyles, community
life, and health services, social and political organization.
The impact of social environment has both positive
and negative aspects on the health of individuals and
communities.
A favourable social environment can improve health,
provide opportunities for man to achieve a sense of
fulfilment, and add to the quality of life.
Risk factors
• For many diseases, the disease “agent” is still
unidentified, e.g. coronary heart disease, cancer,
peptic ulcer, mental illness, etc.
• 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
the development of a disease;
A determinant that can be modified by intervention, thereby
reducing the possibility of occurrence of disease or other
specified outcomes;
• Risk factors are often suggestive, but absolute proof of cause
and effect between a risk factor and disease is usually
lacking.
• The important thing about risk factors is that they are
observable or identifiable prior to the event they predict.
• May be purely additive or synergistic. For example, smoking
and occupational exposure (shoe, leather, rubber, dye and
chemical industries) were found to have an additive effect as
risk factors for bladder cancer.
• May be truly causative, e.g., smoking for lung cancer.
• May be merely contributory to the undesired
outcome, e.g., lack of physical exercise is a risk factor
for coronary heart disease.
• May be predictive only in a statistical sense, e.g.,
illiteracy for perinatal mortality.
• Some are modifiable, some are non modifiable.
References:

• Park K. Park’s Textbook of Preventive and Social Medicine. 23rd ed.

India. Bhanot. P. 33-39.
• Nath, PK. Iceberg phenomenon of disease [Internet]. Place of
Publication (unknown): Community Medicine. 2013 Jan 5 [cited 2018
Apr 15]. Available from:
http://communitymedicineunlimited.blogspot.com/2013/01/iceberg-
phenomenon-of-disease.html
• Prezi. The Iceberg Theory of Disease [Internet]. Place of publication
(unknown): Publisher’s name (not available); 2013 [updated 2013
November 24; cited 2018 Apr 15]. Available from:
https://prezi.com/tyq1z_lphetm/the-iceberg-theory-of-disease/