Gro uping of ill pers on s a nd

Class if icat ion of Disease

Dept Epidemiology

Benfu Yang

1
Introduction
Cause

Association
Groups/Categories

Grouping of events or individuals into

categories is essential to causal inference .

Creation of categories of ill persons

2
• Disease entity
– Symptoms and signs--
cause/prognosis

– Identity/cause---symptoms and signs

3
 process of disease
classification
•Ill persons are grouped into categories such that
the characteristics of the members of each
category permit them to be distinguished from the
members of another category.

•The arrangement of the components of this

nomenclature into groups thought to have common
characteristics (a classification).

4
 Grouping of Ill
Persons
The creation of disease entities involves the
grouping of ill persons into categories that are
believed to have utility in the management of
their illness or in understanding the
circumstance that led to it.
• categories
– natural
– artificial

5
Manifestational and Causal Entities

1.Manifestational criteria: Ill persons are

grouped according to similarity of symptoms,
signs, changes in body chemistry or tissues,
behavior, prognosis, or some combination of
these features.
e.g. fractures, diabetes mellitus,
mental retardation, the common cold,
schizophrenia, and breast caner.
6
2. Causal criteria: Causal grouping depends on
the similarity of individuals with respect to one
or more experiences believed to be the cause of
their illness.

e.g. birth trauma, silicosis, syphilis, lead

poisoning, and, in principle, AIDS.

7
• There is no logical reason to suppose that ill persons classified

together by manifestational or causal criteria will remain as a

group if the other type of criterion is used.

Tubercle bacillus therapy / control of transmission

8
Figure 3-1. Classification of persons with active
tuberculosis (an etiologic entity) according to the
manifestational classification of Cullen

9
• Rubeola
• Rabies
• Tuberculosis
– Smear positive
– Smear negative

10
Lack of necessary congruence between the two ways of
grouping ill persons is important to epidemiologists

1. Polymorphous effects (manifestations ) of

newly isolated causal agents may be
understood
cigarette smoking is associated with several
diseases other than lung cancer
not specific
even if cigarette smoke contained only a single
disease-causing agent,
diversiy of effects. 11
2. It can be understood that an agent causally
associated with a certain manifestational
disease entity may not be causally involved
with all of the ill persons with a particular
manifestation.

Examination of disease subcategories may lead to refinement of the

manifestational entity associated with the identified cause.
e.g. different pathologyic varieties of lung cancer vary
substantially in the strength of their association with cigarette smoking.

No particular manifestational category of coronary artery disease

has been found to be associated with cigarette smoking, although the
high frequency of the disease in nonsmoking indicates clearly that
12
cigarette smoking is not involved in all cases of the disease.
3. The arbitrariness of the distinction between
necessary causes, those without which the
disease does not occur, and contributing causes
will be realized.
necessary cause: M.tuberculosis
contributing factors: age, nutritional status, poverty, genetic
factors

M. tuberculosis may be the necessary cause of tuberculosis

as it is presently defined, but if medical knowledge had
developed differently, many patients now categorized as having
tuberculosis might have been included in a category defined on
the basis of a specific nutritional defect. In this case, the
nutritional factor would have been the necessary cause and the
13
bacillus the contributing factor.
4. It can be understood that not all persons
experiencing the cause will acquire the
disease.

e.g. Although there is a definite causal

association between the tubercle bacillus and
tuberculosis, evidence of internalization of the
bacillus is found in many persons who have no
evidence of illness, just as many persons who
smoke cigarettes do not develop lung cancer.
14
Select ion of C rit eria for Cr eat ion of New Di se ase
Ent it ies

•Particular interest of the observer

determines to a large extent the kind of
criteria selected

e.g. Injuries preventive

therapeutic/prognosis

•In the absence of knowledge of causal

factors, manifestational criteria provide the
only basis for categorization
 Balkan nephropathy
 Mesothelioma (asbestos)
15
• causal factors are identified for manifestatinal entities,

some are used to define new disease entities around

etiologic factors.

• Some newly discovered causal agents have not been

used to develop new disease entities.

e.g., “cigarette smoker’s disease,”

emphysema, carcinoma of the lung, peripheral vascular disease,

coronary artery disease , bladder cancer 16

• Use of one way of grouping ill persons does not

exclude concurrent use of another.

E.g. injuries
– Hospital: fractures, sprains, concussions, and cases of internal

injury

– prevention: automobile accidents, fire, falls, and industrial accidents.

17
 Role of Epidemiologic Observations

• epidemiologic criteria may be used to categorize

groups of persons with specific manifestational
diseases.

– poliomyelitis paralytic disease in Vermont (Caverly)

– typhus Ireland breast-feeding infants, the elderly, and nurses and
others attending the sick
– typhoid fever France and Switzerland (Lombard)

18
•Epidemiological observations may be sufficient
to justify separation of disease entities, even in
the absence of observable manifestational
differences.

•Spirochete: infectious jaundice (Weil’s

disease) occurred in groups, butchers

•Virus: infectious hepatitis/serum hepatitis 19

• Epidemiological evidence suggests that two categories

may usefully be merged, at least for the purpose of

investigation of etiology.

e.g. anencephaly and spina bifida

gender, socioeconomic status, ethnicity, and parity, trends of

frequency over time

20