John Snow

John Snow, born in 1813, was the

son of a coal-yard laborer in York,
England. As a boy he proved to be
an exceptionally bright, methodical,
and eager student, so his mother
used a small inheritance to send
him to a private school, where he
excelled.
Cholera
In the summer of 1831, when
Snow was eighteen and in his
fourth year as an apprentice,
an epidemic of cholera struck
London.
The first symptom of cholera was
queasiness, followed by
stomachache, vomiting, and
diarrhea so profuse that it caused
victims to die of dehydration.
Snow continued to treat cholera
patients until February of 1832,
when the epidemic ended as
suddenly and mysteriously as it
had begun.
Second Cholera
outbreak
In September of 1848, when Snow
was thirty-five, a new outbreak of
cholera struck London.
He decided to track the progress of
the disease.
He tried see if he could determine
exactly how it was spread.
Snows study of Cholera
Snow was a sceptic of the then-
dominant miasma theory that stated that
diseases such as cholera and bubonic
plague were caused by pollution or a
noxious form of "bad air".
The germ theory of disease had not yet
been developed, so Snow did not
understand the mechanism by which the
disease was transmitted.
His observation of the evidence led him
to discount the theory of foul air.
Broad Street Snows
Map

Broad St. Pump
On proceeding to the spot, I found
that nearly all the deaths had taken
place within a short distance of the
[Broad Street] pump.
There were only ten deaths in
houses situated decidedly nearer
to another street-pump.
In five of these cases the families
of the deceased persons informed
me that they always sent to the
pump in Broad Street, as they
preferred the water to that of the
pumps which were nearer.
In three other cases, the deceased
were children who went to school
near the pump in Broad Street...

Final conclusion of the
Cholera causes
Researchers later discovered that
this public well had been dug only
three feet from an old cesspit,
which had begun to leak fecal
bacteria.
The nappies of a baby, who had
contracted cholera from another
source, had been washed into this
cesspit.
Natural History of
Disease
Background
Infectious disease epidemiology
the occurrence of infectious disease in a
given host is dependent on the presence
of disease in other members of the
population and the length of time that
infected hosts are able to transmit
disease to others
understanding these characteristics of a
disease allow us to develop rational
measures to control disease
Definition & Stages
Definition ; The course of a disease from onset
(inception) to resolution.

Stages
Stage of
pathologic
onset
Pre-symptomatic
stage
Clinically
manifest disease
Progress to a fatal termination
Remission and relapses
Regress spontaneously,
leading to recovery
Risk Factors Precursors Effect of Treatment Prognostic factor
Risk factor
Risk factor; An aspect of personal behavior or life
style, an environmental exposure, or an inborn or
inherited characteristic, that, in the basis of
epidemiologic evidence, is known to be associated
with health-related condition (s) considered important
to prevent.
Risk marker; increased probability of a specified
outcome; not necessarily a causal factor
Determinant; can be modified by intervention,
thereby reducing the probability of occurrence of
disease or other specified outcomes
(A) (P) (S) (M) (D) (T)
The Natural history of disease in a
patient
A ; Biologic onset of disease
P ; Pathologic evidence of disease if Sought
S ; Signs and symptoms of disease
M ; Medical care sought
D ; Diagnosis
T ; Treatment
Preclinical Phase Clinical Phase
THE NATURAL HISTORY OF A DISEASE
STIMULUS to
the HOST
HOST REACTION RECOVERY
interrelation of
Agent, Host and
Environmental
factors
Latent Period (Pre-
symptomatic)
Symptoms,
Signs(Clinical)
with or without Defects,
Disability
PREPATHOGE
NESIS
PERIOD OF PATHOGENESIS
Health
Promotion
Specific
Protection

Early Diagnosis and Prompt
Treatment,
Disability Limitation

Rehabilitation
PRIMARY
PREVENTION
SECONDARY
PREVENTION
TREATMENT TERTIARY PREVENTION
(Leavell's Level of Application of Preventive Medicine)
Susceptible
host
TIME
Incubation period
Death
Recovery
Exposure Onset
Latent
Infectious
Non-infectious
Infection
No infection
Clinical disease
Latent period
the time interval from infection to
development of infectiousness
Infectious period
the time during which time the host can infect
another susceptible host
Non-infectious period
the period when the hosts ability to transmit
disease to other hosts ceases
Incubation period
the time interval between infection to
development of clinical disease
e.g : Chicken pox
an infectious disease caused by the
varicella-zoster virus
the latent period for chicken pox is shorter
than the incubation period, so a child with
chicken pox becomes infectious to others
before developing symptoms

Susceptible
host
TIME
Incubation period
Death
Recovery
Exposure Onset
Latent
Infectious
Non-infectious
Infection
No infection
Clinical disease
Other examples?
HIV (AIDS)
latent period relatively short
infectious period occurs (many years) BEFORE
the onset of symptoms
Susceptible
host
TIME
Incubation period
Death
Recovery
Exposure Onset
Latent
Infectious
Infection
No infection
Clinical disease
e.g : Malaria
caused by protozoan parasites of the genus
Plasmodium
the stages of the parasite that are infective
to mosquitoes occur about 10 days after the
development of symptoms
latent period is around 10 days longer than
the incubation period, so early treatment of
symptoms could have an important effect on
transmission
Natural history of disease
Susceptible
host
TIME
Incubation period
Death
Recovery
Exposure Onset
Latent
Infection
No infection
Clinical disease
Infectious
Latent Period of Chronic
Disease
Definition; "Interval between exposure to a disease-
causing agent and the appearance of manifestations of
the disease
Incubation period in infectious disease
Two possible conditions
1) brief exposure
2) prolonged or continuous exposure
Primary Prevention
'Preventing the occurrence of disease or injury by
modifying risk factors.'
'Various aspects are considered to produce effective
primary prevention program. Especially, advancing
knowledge of disease causation must be required.

Primary Prevention
** Guidelines for effective prevention programs(RB
Wallace, GD Everett,1986)
Programs must be based on scientific evidence.
Prevention programs should be supported by effective
data system.
Programs should be flexible.
Programs must be sensitive to ethical issues.
Programs should be targeted to the recipients most in
need.
Programs should muster a variety of community
resources.
Effective prevention requires legislative action and
social policy decisions.
Programs should be continuous.

Primary Prevention
General health promotion
'Proper nutrition, mental hygiene, adequate housing, and appropriate
balance between work and play, est and exercise, and useful and
productive place in society, are among the best recognized factors
ontributing to maintenance of optimum health.(Commission on Chronic
illness, USA, 1957)
Specific protection
Health Promotion
'Health promotion is any combination of educational, organizational,
economic, and environmental supports for behavior and conditions of
living conducive to health (LW Green, 1992).'
Criteria for the Development of Health
Promotion and Education Programs
A health promotion program should address one or more risk
factors which are carefully defined, measurable, modifiable,
and prevalent among the members of a chosen group, factors
which constitute a threat to the health status and the quality of
life of target group members.
A health promotion program should reflect a consideration of
the special characteristics, needs, and preferences of its target
groups(s)
Criteria for the Development of Health
Promotion and Education Programs
health promotion programs should include interventions which will
clearly and effectively reduce a targeted risk factor and are appropriate
for a particular setting
A health promotion program should identify and implement
interventions which make optimum use of available resources.
From the outset, a health promotion program should be organized,
planned, and implemented in such a way that its operation and effects
can be evaluated.

Secondary Prevention
'Early detection and intervention, preferably before the
condition is clinically apparent, and has the aim of
reversing, halting, or at least retarding the progress of a
condition.

'It sometimes happens that a patient first becomes aware
of a disease when it is already too late for it to be
successfully treated.
Tertiary Prevention
'Minimizing the effects of disease and disability
by surveillance and maintenance aimed at
preventing complications and premature
deterioration'

Medical rehabilitation

Social rehabilitation