Skip to main content Accessibility help

Updating the epidemiological transition model

  • A. J. Mercer (a1)


The main feature of the epidemiological transition is a shift in the recorded causes of death from infectious diseases to other morbid conditions. This paper outlines modifications made to Omran's original model and stages of transition, and suggests that without a focus on aetiology and morbidity, these have been basically descriptive rather than explanatory, and potentially misleading because infections have been confirmed as causes of various chronic diseases. Common infections and related immune responses or inflammatory processes contribute to the multifactorial aetiology of morbid conditions that together make a substantial contribution to overall mortality, and infectious causation is suspected for many others because of strong evidence of association. Investigation into possible infectious causes of conditions frequently recorded as the underlying cause of death can be integrated into a framework for comparative research on patterns of disease and mortality in support of public health and prevention. A theory of epidemiological transition aimed at understanding changes in disease patterns can encompass the role in different conditions and chronic diseases of infections contracted over the life course, and their contribution to disability, morbidity and mortality relative to other causes and determinants.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Updating the epidemiological transition model
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Updating the epidemiological transition model
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Updating the epidemiological transition model
      Available formats


Corresponding author

Author for correspondence: A. J. Mercer, E-mail:


Hide All
1.Defo, BK (2014) Beyond the ‘transition’ frameworks: the cross-continuum of health, disease and mortality framework. Global Health Action 7, 24804. Published online: 5 May 2014.
2.Defo, BK (2014) Demographic, epidemiological, and health transitions: are they relevant to population health patterns in Africa? Global Health Action 7, 24804. Published online: 15 May 2014.
3.Santosa, A, et al. (2014) The development and experience of epidemiological transition theory over four decades: a systematic review. Global Health Action 7, 23574. Published online: 15 May 2014.
4.Fleischer, NL and McKeown, RE (2014) The second epidemiologic transition from an epidemiologist's perspective. In Zuckerman, MK (ed.). Modern Environments and Human Health: Revisiting the Second Epidemiologic Transition. Hoboken, NJ: Wiley-Blackwell, pp. 353369.
5.Zuckerman, MK, et al. (2014) The evolution of disease: anthropological perspectives on epidemiological transitions. Global Health Action 7, 23303. Published online: 15 May 2014.
6.Omran, OR (1971) The epidemiologic transition. Milbank Memorial Fund Quarterly 49, 509538.
7.Cochran, GM, Ewald, PW and Cochran, KD (2000) Infectious causation of disease: an evolutionary perspective. Perspectives in Biology and Medicine 43, 406448.
8.World Health Organization (2016) International Statistical Classification of Diseases and Related Health Problems, 10th revision, 5th edn. Geneva: World Health Organization. Available at [Accessed 19 August 2017].
9.Barrett, R, et al. (1998) Emerging and re-emerging infectious diseases. The third epidemiologic transition. Annual Review of Anthropology 27, 247271.
10.Armelagos, GJ (2004) Emerging disease in the third epidemiological transition. In Mascie-Taylor, CGN, Peters, J, Garvey, ST (eds). The Changing Face of Disease: Implications for Society. Boca Raton, Florida: CRC Press, pp. 722.
11.Harper, K and Armelagos, G (2010) The changing disease-scape in the third epidemiological transition. International Journal of Environmental Research and Public Health 7, 675697.
12.Vallin, J and Meslé, F (2004) Convergences and divergences in mortality. A new approach to health transition. Demographic Research S2, 1144. Published online: 16 April 2004. doi: 10.4054/demres.2004.s2.2.
13.Frenk, J, et al. (1991) Elements for a theory of the health transition. Health Transition Review 1, 2138.
14.Omran, OR (1998) The epidemiologic transition theory revisited thirty years later. World Health Statistics Quarterly 51, 99119.
15.Omran, OR (1983) The epidemiologic transition theory. A preliminary update. Journal of Tropical Paediatrics 29, 305316.
16.Olshansky, SJ and Ault, AB (1986) The fourth stage of the epidemiologic transition: the age of delayed degenerative diseases. Milbank Memorial Fund Quarterly 64, 355391.
17.Mercer, A (2014) Infections, Chronic Disease, and the Epidemiological Transition. A New Perspective. Rochester Studies in Medical History. Rochester, NY: University of Rochester Press.
18.Mackenbach, JP (1994) The epidemiologic transition theory. Journal of Epidemiology and Community Health 48, 329332.
19.Caldwell, JC (2001) Population health in transition. Bulletin of the World Health Organisation 79, 159160.
20.McKeown, T and Record, RG (1962) Reasons for the decline in mortality in England and Wales during the nineteenth century. Population Studies 16, 94122.
21.McKeown, T (1976) The Modern Rise of Population. London: Edward Arnold.
22.Fogel, RW (2012) Explaining Long-Term Trends in Health and Longevity. Cambridge: Cambridge University Press.
23.Mercer, AJ (2016) Long-term trends in cardiovascular disease mortality and association with respiratory disease. Epidemiology and Infection 144, 777786. Published online 5 August 2015. http://dx.doi:10.1017/S0950268815001818.
24.Gaziano, JM (2010) Fifth phase of the epidemiologic transition. Journal of the American Medical Association 303, 275276.
25.Rogers, GR and Hackenberg, R (1987) Extending epidemiologic transition theory: a new stage. Social Biology 34, 234243.
26.Olshansky, SJ, et al. (1998) Emerging infectious diseases: the fifth stage of the epidemiologic transition? World Health Statistics Quarterly 51, 207217.
27.Lorber, B (2012) Infectious causes of chronic illness: an overview. Microbe 7, 5963.
28.Preston, SH (1975) The changing relation between mortality and level of development. Population Studies 29, 231245.
29.Preston, SH (1976) Mortality Patterns in National Populations – with Special Reference to Recorded Causes of Death. New York: Academic Press.
30.Easterlin, RA (1999) How beneficient is the market? A look at the modern history of mortality. European Review of Economic History 3, 257294.
31.Caldwell, JC (1993) Health transition: the cultural, social and behavioural determinants of health in the Third World. Social Science and Medicine 36, 125135.
32.CSDH (2008) Closing the Gap in A Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization.
33.Gwatkin, DR (2001) Poverty and inequalities in health within developing countries: filling the information gap. In Leon, D, Walt, G (eds). Poverty, Inequality, and Health. Oxford: Oxford University Press, pp. 217246.
34.Kunitz, SJ. (1990) The value of particularism in the study of the cultural, social and behavioural determinants of mortality. In: Caldwell, JC, et al. (eds). What We Know About Health Transition: The Cultural, Social, and Behavioural Determinants of Health. Proceedings of an International Workshop, Canberra, Vol. I. Canberra: The Australian National University, pp. 92109.
35.Krieger, N (2005) Embodiment: a conceptual glossary for epidemiology. Journal of Epidemiology and Community Health 59, 350355.
36.McKeown, RE (2009) The epidemiologic transition: changing patterns of mortality and population dynamics. American Journal of Lifestyle Medicine 3(Suppl. 1), 19S26S.
37.Zuckerman, MK and Armelagos, GJ (2014) The hygiene hypothesis and the second epidemiologic transition. In Zuckerman, MK (ed.). Modern Environments and Human Health: Revisiting the Second Epidemiologic Transition. Hoboken, NJ: Wiley-Blackwell, pp. 301320.
38.O'Connor, SM, Taylor, CE and Hughes, JM (2006) Emerging infectious determinants of chronic diseases. Emerging Infectious Diseases 12, 10511057.
39.MacMahon, B and Pugh, TF (1970) Epidemiology Principles and Methods. Edinburgh and London: Churchill/Livingstone.
40.Carbonne, KM, Luftig, RB and Buckley, MR (2005) Microbial Triggers of Chronic Human Illness. Report on a colloquium sponsored by the American Academy of Microbiology, June 25–27. Washington DC: American Academy of Microbiology.
41.Hill, AB (1965) The environment and disease: association or causation? Proceedings of the Royal Society of Medicine 58, 295300.
42.Vandenbroucke, JP, Broadbent, A and Pearce, N (2016) Causality and causal inference in epidemiology: the need for a pluralistic approach. International Journal of Epidemiology 45, 17761786. Published online: 22 January 2016. doi: 10.1093/ije/dyv34.
43.Marshall, BJ and Warren, JR (1984) Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet 323, 13111315.
44.Marshall, B (2002) Commentary: Helicobacter as the ‘environmental factor’ in Susser and Stein's cohort theory of peptic ulcer disease. International Journal of Epidemiology 31, 2122.
45.Ewald, PW (2002) Plague Time – The New Germ Theory of Disease. New York: Anchor Books.
46.Knobler, SL, et al. (eds). (2004) The Infectious Aetiology of Chronic Diseases: Defining the Relationship, Enhancing the Research, and Mitigating the Effects – Workshop Summary. Forum on Emerging Infections, Institute of Medicine. Washington DC: The National Academies Press (US).
47.Campbell, LA, Kuo, C and Grayston, JT (1998) Chlamydia pneumoniae and cardiovascular disease. Emerging Infectious Diseases 4, 571579.
48.Kalayoglu, MV, Libby, P and Byrne, GI (2002) Chlamydia pneumoniae as an emerging risk factor in cardiovascular disease. Journal of the American Medical Association 288, 27242731.
49.Morré, SA, et al. (2000) Microorganisms in the aetiology of atherosclerosis. Journal of Clinical Pathology 53, 647654.
50.Ngeh, J, Anand, V and Gupta, S (2002) Chlamydia pneumoniae and atherosclerosis – what we know and what we don't know. Clinical Microbiology and Infection 8, 213.
51.Mussa, F, et al. (2006) Chlamydia pneumoniae and vascular disease: an update. Journal of Vascular Surgery 43, 13011307.
52.Kiechl, S, et al. (2001) Chronic infections and the risk of carotid atherosclerosis. Circulation 103, 10641070.
53.Karbasi-Afshar, R, Khedmat, H and Izadi, M (2015) Helicobacter pylori infection and atherosclerosis: a systematic review. Acta Medica Iranica 53, 7888.
54.Patel, P, et al. (1995) Association of Helicobacter pylori and Chlamydia pneumoniae infections with coronary heart disease and cardiovascular risk factors. British Medical Journal 311, 711714.
55.Rosenfeld, ME and Campbell, LA (2011) Pathogens and atherosclerosis: update on the potential contribution of multiple infectious organisms to the pathogenesis of atherosclerosis. Thrombosis and Haemostasis 106, 858867.
56.Joshi, R, et al. (2013) Chlamydophila pneumoniae infection and cardiovascular disease. North American Journal of Medical Sciences 5, 169181.
57.Heltai, K, et al. (2004) Elevated antibody levels against Chlamydia pneumoniae, human HSP60 and mycobacterial HSP65 are independent risk factors in myocardial infarction and ischaemic heart disease. Atherosclerosis 173, 339346.
58.Smeeth, L, et al. (2004) Risk of myocardial infarction and stroke after acute infection or vaccination. New England Journal of Medicine 35, 26112618.
59.Corrales-Medina, VF, Madjid, M and Musher, DM (2010) Role of acute infection in triggering acute coronary syndromes. Lancet Infectious Diseases 10, 8392.
60.Warren-Gash, C, Smeeth, L and Hayward, AC (2009) Influenza as a trigger for acute myocardial infarction or death from cardiovascular disease: a systematic review. Lancet Infectious Diseases 9, 601610.
61.Clar, C, et al. (2015) Influenza vaccines for preventing cardiovascular disease. Cochrane Database Systematic Reviews (5), CD005050. Published online: 5 May 2015. doi: 10.1002/14651858.CD005050.pub3.
62.National Heart Lung and Blood Institute (1994) Report of the Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases. Rockville, Maryland: National Institutes of Health.
63.Davey Smith, G, Gunnell, D and Ben-Shlomo, Y (2001) Life-course approaches to socio-economic differentials in cause-specific adult mortality. In Leon, DA, Walt, G (eds). Poverty, Inequality, and Health. Oxford: Oxford University Press, pp. 88124.
64.Madjid, M, et al. (2004) Influenza and cardiovascular disease – is there a causal relationship? Texas Heart Institute Journal 31, 413.
65.Littman, AJ, Jackson, LA and Vaughan, TL (2005) Chlamydia pneumoniae and lung cancer: epidemiologic evidence. Cancer Epidemiology Biomarkers and Prevention 14, 773778.
66.Zhan, P, et al. (2011) Chlamydia pneumoniae infection and lung cancer risk: a meta-analysis. European Journal of Cancer 47, 742747.
67.Liang, H, et al. (2009) Facts and fiction of the relationship between pre-existing tuberculosis and lung cancer risk: a systematic review. International Journal of Cancer 125, 29362944.
68.Brenner, DR, et al. (2012) Previous lung diseases and lung cancer risk: a pooled analysis from the International Lung Cancer Consortium. American Journal of Epidemiology 176, 573585. Published online: 17 September 2012. doi: 10.1093/aje/kws151.
69.Bobba, RK, et al. (2011) Scar carcinoma of the lung: a historical perspective. Clinical Lung Cancer 12, 148154.
70.Eurogast Study Group (1993) An international association between Helicobacter pylori infection and gastric cancer. Lancet 341, 13591362.
71.International Agency for Research on Cancer (1994) IARC working group on the evaluation of carcinogenic risks to humans. In Schistosomes, Liver Flukes, and Helicobacter pylori. IARC Monograph 61. Lyon: IARC, pp. 177240. Martel, C, et al. (2012) Global burden of cancers attributable to infections in 2008: a review and synthetic analysis. Lancet Oncology 13, 607615.
73.Bouvard, V, et al. (2009) A review of human carcinogens – Part B: biological agents. Lancet Oncology 10, 321322.
74.Lawson, JS, Glenn, WK and Whitaker, MJ (2016) Human papilloma viruses and breast cancer – assessment of causality. Frontiers in Oncology 6, 207. doi: 10.3389/fonc.2016.00207.
75.Lawson, JS and Heng, B (2010) Viruses and breast cancer. Cancers 2, 752772. doi: 10.3390/cancers2020752.
76.Mason, AL, Gilady, SY and Mackey, JR (2011) Mouse mammary tumor virus in human breast cancer: red herring or smoking gun? The American Journal of Pathology 179, 15881590.
77.GBD 2015 Mortality and Cause of Death Collaborators (2016) Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388, 14591544.
78.Office for National Statistics, UK Statistics Authority (2014) Mortality Statistics: Deaths Registered in England and Wales (Series DR). Tichfield, UK: Office for National Statistics.
79.Manollo, TA, et al. (2009) Finding the missing heritability of complex diseases. Nature 461, 747753. Published online: 8 October 2009. doi: 10.1038/nature08494.
80.Bjerke, W (2011) The impact of infectious disease on chronic disease: a review of contemporary findings. Journal of Social Behavioural and Health Sciences 5, 4557.
81.Beaglehole, R, et al. (2011) Priority actions for the non-communicable disease crisis. Lancet 377, 14381447.
82.Beaglehole, R and Yach, D (2003) Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. Lancet 362, 903908.
83.Pearson, TA (2003) Education and income: double-edged swords in the epidemiologic transition of cardiovascular disease. Ethnicity and Disease 13(Suppl. 2), S158S163.
84.Dye, C (2014) After 2015: infectious diseases in a new era of health and development. Philosophical Transactions of the Royal Society B: Biological Sciences 369, 20130426. Published online.
85.Mosley, WH and Gray, R (1993) Childhood precursors of adult morbidity and mortality in developing countries: implications for health programmes. In: Gribble, JN, Preston, SH, (eds). The Epidemiological Transition: Policy and Planning Implications for Developing Countries. Washington DC: National Academy Press, pp. 69100.
86.World Health Organization (2013) Comprehensive Cervical Prevention and Control: A Healthier Future for Girls and Women. WHO Guidance Note. Geneva: WHO Press.
87.Reichart, TA, et al. (2001) The Japanese experience with vaccinating schoolchildren against influenza. New England Journal of Medicine 344, 889896.
88.Wong, BC, et al. (2004) Helicobacter pylori eradication to prevent gastric cancer in a high-risk region of China. A randomised controlled trial. Journal of the American Medical Association 291, 187194.
89.You, W, et al. (2000) Gastric dysplasia and gastric cancer: Helicobacter pylori, serum vitamin C, and other risk factors. Journal of the National Cancer Institute 92, 16071611.
90.Romeri, E, Baker, A and Griffiths, G (2006) Mortality by deprivation and cause of death in England and Wales, 1999–2003. Health Statistics Quarterly 32, 1934.
91.Gwatkin, DR, et al. (2007) Socio-Economic Differences in Health, Nutrition, and Population Within Developing Countries: An Overview. Washington, DC: World Bank.
92.Pearce, N (1996) Traditional epidemiology, modern epidemiology, and public health. American Journal of Public Health 86, 678683.
93.Link, BG and Phelan, JC (2002) McKeown and the idea that social conditions are fundamental causes of disease. American Journal of Public Health 92, 730732.
94.Colgrove, J (2002) The McKeown thesis: a historical controversy and its enduring influence. American Journal of Public Health 92, 725729.
95.Grundy, E (2005) Commentary: the McKeown debate: time for burial. International Journal of Epidemiology 34, 529533.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed