NATURAL HISTORY

OF DISEASE
Perjalanan Alamiah Penyakit

dr. Erlina Marfianti, MSc, SpPD

Internal Medicine Department
Medical Faculty
UII
 Natural History of Disease
• The progress of a disease process in
an individual over time, in the
absence of intervention.
• The process begins with exposure to
or accumulation of factors capable of
causing disease.
• Without medical intervention, the
process ends with
recovery ,disability, or death

2
Natural History of Disease
Information from Natural
History of Disease

• Incubation period, Latent period

• Symptomp
• Time and Place  frequency
• Biologic Aspect of Pathogent
NHD , Is it Important ?

TECHNOLOGY

PREVENTIF CONTROL
DIAGNOSIS SURVEILANCE
MANAGEMENT PROGRAM
THERAPY

PROGNOSIS
Natural History of Disease TECHNOLOGY

Exposure to Agent
Symptom Development

Pre-exposure
Preclinical
Stage:
Stage:
Factors present Clinical Stage: Resolution Stage:
Exposure to
leading to problem
causative agent: Symptoms present Problem resolved.
development
no symptoms Returned to health or

present chronic state or death

Primary Prevention Secondary Tertiary Prevention

Prevention

6
Infection Disease
Communicable disease :
TBC, Malaria, HIV
Non Communicable disease:
Degenerative Disease/Chronic
Disease : DM, Heart Disease
Malignancy
Others
 Epidemiologic Triad

Disease is the result of forces

within a dynamic system

consisting of:

agent of infection

host

environment
 Factors Influencing Disease

Agent Environment

• Infectivity • Weather

• Pathogenicity DISEASE • Housing

• Virulence • Geography

• Immunogenicity • Occupational setting

• Antigenic stability • Age • Air quality

Host

• Survival • Sex • Food

• Genotype
•
(www)
• Infectivity refers to the proportion of
Naturalpersons
exposed Historywho
andbecome
Spectrum of
infected.
Disease refers to the proportion of
• Pathogenicity
infected persons who develop clinical
disease.
• Virulence refers to the proportion of
persons with clinical disease who become
severely ill or die
Stage

•PREPATHOGENESIS
•PATHOGENESIS
•PASCAPATHOGENESIS
Prepathogenesis
Agent – Host Interaction
No disease
Immunity factor
Healthy person
Pathogenesis
Incubation period
Subclinical Stage of disease
(early disease)
Clinical Stage of disease
Pasca/PostPathogenesis
Death
Disability
Chronic
Carrier
Cure, Recovery
 RIWAYAT ALAMIAH PENYAKIT

MASA PRE- MASA

PASCA
PATHOGENESIS PATHOGENESIS PATHOGENESIS

Masa Meninggal
Masa
lanjut Sakit
Masa
Kronis
awal penyembuhan
Cacat
H sakit
A
Sembuh
H A HORIZON KLINIS

A
H
Awal terjadi
EE E
Sakit Waktu

Tempat
Keseimbangan
Pergeseran Orang
Interaksikeseimbangan
 NATURAL HISTORY OF

DISEASE

• Generally (Pre-Pathogenesis-
Post)
• SPESIFIC (/ disease)
• Some disease  have similar
• Different in incubation period, etc
NATURAL HISTORY OF
INFECTION DISEASE
 Factors Influencing Disease Transmission

Agent Environment
• Weather
• Infectivity
• Housing
• Pathogenicity
• Geography
• Virulence
• Occupational setting
• Immunogenicity
• Air quality
• Antigenic stability
• Food
• Survival

• Age
• Sex
• Genotype
Host
• Behaviour
• Nutritional status
• Health status
(www)
Trias

Disea disebabkan adanya interaksi antara agen penyebab penyakit dengan manusia yang rentan

dan didukung oleh keadaan lingkungan yang sesuai

Agents Factor

Agents, caused disease is consist of life or non life agents:

1. Biologic Agents
virus, bacteri, protozoa, jamur, cacing, and insecta.
2. Chemical Agents
From external factors (toxin, drug, chemical) or internal
factors (ureum, kolesterol)
Agents Factor

3. Physical Agents
Thermal (burn ), physical trauma
radiation, etc
4. Nutritional Agents
Protein, lipid, carbohydrat, vitamin, mineral, and
water.
5. Psikis Agents
Stressor, mental disorder
HOST Factors
• intrinsic factors: (susceptibility), respon againts
pathogen
– EX : Age, Gender, Life Style  Risc
– Genetic, Nutrition status, Immune Status
Environtmental Factors

extrinsic factors

• Physical Factors (e.g. geographic)

• Biological Factors (e.g. vectors – )
• Structural Factors (Sanitation, Health system)
 Infectious Disease

Definitions
 Infectious diseases Tetanus Measles

 Caused by an infectious agent

 Communicable diseases
 Transmission – directly or indirectly – from an infected person
 Transmissible diseases
 Transmission – through unnatural routes – from an infected person

Note
 Infections are often subclinical – infections vs infectious diseases!
 Antonyms not well-defined
 Non-communicable diseases – virus involved in pathogenesis of diabetes?
 Chronic diseases – HIV?

(www)
Agent - host relationship

Agent Habitat where agent survives or propagates

Reservoir

Mode of transmission

Many diseases have

multiple reservoirs and modes of Host

transmission

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Typical course of infectious disease

TIME

Subclinical Death
Susceptible
Disease
Host

Clinical

Disease
No

infection

Recovery

Incubation period

Exposure Onset

27
Induction + latency = incubation
TIME

Susceptible Subclinical Clinical

Host Disease Disease

Induction

Latency

Incubation
Clinical onset
Exposure Disease onset

28
Latency and infectiousness
TIME

Susceptible Subclinical Clinical Death

Host Disease Disease Recovery

Latent Infectious Non-infectious

Incubation

Infection Clinical onset

29
 Exposure to Infectious Agents

No infection Clinical Sub-clinical Carrier

Outcome

Death Carrier Immunity No immunity

(www)
 Timeline for Infection

Infection
Dynamics of Latent Infectious Non-infectious

infectiousness period period

Susceptible

Time
Infection

Dynamics of Incubation Symptomatic Non-diseased

disease period period

Susceptible

Time

(www)
 “Iceberg” concept of infectious disease
in populations

DEATH

CLINICAL

DISEASE SEVERE

DISEASE

SUB CLINICAL MILD ILLNESS

DISEASE

INFECTION WITHOUT

CLINICAL ILLNESS

EXPOSURE WITHOUT INFECTION

32
Transmission Mechanisms

Infected S usceptible
D irect
hostIn
host
di
re
ct

V ector

33
CHAIN OF INFECTION

EPIDEMIOLOGY /
A case is a risk factor …
 Infection in one person can be transmitted to others

(www)
 What is infectious disease
epidemiology?

The cause often known

 An infectious agent is a necessary cause

What is infectious disease epidemiology then used for?

 Identification of causes of new, emerging infections, e.g. HIV, vCJD, SARS
 Surveillence of infectious disease
 Identification of source of outbreaks
 Studies of routes of transmission and natural history of infections
 Identification of new interventions

(www)
Modes of Disease Transmission
Some Pathogens that Cross the Placenta
 Transmission

Cases
 Index – the first case identified
 Primary – the case that brings the infection into a population
 Secondary – infected by a primary case
 Tertiary – infected by a secondary case
T
S

Susceptible P
S

Immune
S
T
Sub-clinical

Clinical

(www)
 Chain of Infection

Horton & Parker: Informed Infection Control Practice (www)

Iceberg Concept of Infection
 Reservoirs

A host that carries a pathogen without

injury to itself and serves as a source of

infection for other host organisms

(asymptomatic infective carriers)

(www)
 Reservoirs

Humans

{hepatitis}

Other Vertebrates

{zoonoses}

Birds & Bats

{histoplasmosis}
 Vectors

A host that carries a pathogen without

injury to itself and spreads the pathogen

to susceptible organisms

(asymptomatic carriers of pathogens)

Example of a Web of
Causation TBC

Overcrowding
Malnutrition

Exposure to

Mycobacterium

Susceptible Host
Infection Tuberculosis

Tissue Invasion and Reaction

Vaccination
Genetic

46
Infection Cycle of Schistosomiasis

Peters: Tropical Medicine and Parasitology, 2001 (www)

Infection Cycle of Leishmaniasis

Lipoldova & Demand, 2006 (www)

LEVEL OF PREVENTION

1. Primordial Prevention
2. Primary Prevention
3. Secondary Prevention
4. Tertiary Prevention
 Natural history of disease
Interrelation of Agent , Host and Reaction of the host to the stimulus
Environmental Factor

Production of stimulus Early Discernible Advance Convalescence

pathogenesis early lesions disease

Pre-pathogenesis period Period of Pathogenesis

Health Promotion Specific protection Early diagnosis & Disability Rehabilitation
prompt treatment limitation
•Health Education •Use of specific •Case finding measures •Adequate •Provision of
•Good standard of immunization individual & mass treatment to hospital &
nutrition adjusted to •Attention to personal •Screening surveys arrest the community facilities
developmental phases hygiene disease for retaining &
•Selective examinations
of life process and to education for
•Use of environmental objectives
prevent further maximum use of
•Attention of sanitation To cure & prevent complications remaining capacities
personality •Protection against disease process
development occupational hazards •Education of public
To prevent the spread of & industry the
•Provision of adequate •Protection from a communicable diseases •Provision of
rehabilitated
housing recreation & accidents facilities to
To prevent complications
agreeable working limit disability •As full employment
•Use of specific & sequel as possible
cond. and to prevent
nutrients To shorten period of
•Marriage counseling death •Selective
•Protection of disability placement
ang sex education
carcinogens
•Genetics •Work therapy in
•Avoidance of allergens hospitals
•Periodic selective
examination •Use of shelter
colony
Primary prevention Secondary Prevention Tertiary prevention
Natural History Of Chronic
Disease

HEART DISEASE

DIABETES MELLITUS
CHD Pathology: Coronary Artery
Sections
Normal Artery
Muscle Wall

Endothelium

Open Lumen

Atheroma Plaque
Then plaque ruptures

& triggers clotting

Thrombus
 The LONG Natural History of CHD

Symptoms
CHD
f
Symptom threshold al C
ours
eo
2 .5

a tur
N

No Symptoms

0 .5
 Atheroma
Childhood Middle Age Old Age
Atheroma & Thrombosis

Hanlon, Capewell et al 1997

 CHD starts early, presents later


Symptoms 

CHD
f
Symptom threshold al C
ours
eo
2 .5

a tur
N

No Symptoms

0 .5
 Atheroma
Childhood Middle Age Old Age
Inflammation &

Thrombosis
 CHD starts early, presents later


Symptoms 

CHD
f
Symptom threshold al C
ours
eo
2 .5

a tur 
N

No Symptoms

0 .5
 Atheroma
Childhood Middle Age Old Age
Atheroma & Thrombosis
 CHD Prevention options

Symptoms
HD
SECONDARY
f C
Symptom threshold al C our
se
o
PREVENTION
tur
Na
2 .5

No Symptoms

0 .5

Childhood Middle Age Old Age

 CHD Prevention options

Symptoms
HD
SECONDARY
f C
Symptom threshold al C our
se
o
PREVENTION
tur
Na
2 .5

( for survivors)
No Symptoms

0 .5

Childhood Middle Age Old Age

 CHD Prevention options

Symptoms
SECONDARY
HD
fC
Symptom threshold C our
se
o PREVENTION
al
tur
2 .5

Na

No Symptoms

PRIMARY PREVENTION
0 .5

Childhood Middle Age Old Age

CVD
Risk Factor
Paradigm:
solid
evidence
base

IMPLEMENT THE DIET ACTION PLAN NOW

 Population CVD
Biological Combined
Policies & Patient OUTPUTS
Risk Factors CVD Risk
Behaviours Groups
Diabetes

or
SUDS NON-SUDS
Physical
IGT
Unstable Chronic
Activity
Angina
Obesity
Angina
CHD
(BMI)

Death
Diet Cholesterol

Combined

CVD Risk
LDL
Early
(& HDL) Acute From
Heart
MI any

Failure State

Smoking Blood
Recurrent Severe
Pressure
MI Heart

Failure Non-CHD
MI

survivors
Death

Deprivation

Additional
Stroke
CVD
PAD
Risk Factors
etc

Populations: UK>E&W>Regions>PCTs

Outputs: Population-based incidence, prevalence; Deaths prevented; Life-Years; Life expectancy; Costs; Cost-effectiveness ratios
 International Diabetes Federation Definition:

Abdominal obesity plus two other components: elevated BP, low HDL,

elevated TG, or impaired fasting glucose

ALHAMDULILLAH