Measures of Disease Occurrence

Dr. H. Mohammed

Objectives
To describe measures of disease occurrence and frequency of health events To calculate measures of disease frequency

Types of Measures
Epidemiology is concerned with the presence of health problems or the occurrence of new health events in a population The most common types of measures are:
Counts Ratios Proportions Rates

Types of Measures
Count = Number of animals who have a particular disease
5,000 cows in St. Kitts have mastitis

Types of Measures
Ratio = A fraction in which the numerator is not part of the denominator e.g. Fetal death ratio: Fetal deaths/live births By definition, fetal deaths are not included among live births

Types of Measures
Proportion = A fraction in which the numerator is part of the denominator e.g. Fetal death rate: Fetal deaths/all births All births include both live births and fetal deaths

Proportions
Synonyms include:
Risk Percentage (if expressed as a value per 100)

Hint:
Most fractions in epidemiology are proportions

Types of Measures
Rate An expression of the frequency with which an event occurs in a defined population
There is a relationship between the numerator and the denominator and a specified time period
e.g. 0.36 per 1,000 pigs reported with swine flu in 1997-98

A proportion in which change over time is considered

However, is often used interchangeably with proportion (without reference to time)

Measures of Disease Frequency

When measuring it is important in epidemiology to define: What is being measured? Person or animals included Place or location of the study population Time period of the study

Measures of Disease Frequency

When measuring it is important in epidemiology to define: What Vaccination status of equines Animals Equines Place Nevis Time JulNov 2009

Measures of Disease Frequency

This helps to: Define the population at risk Clarify relationships between the numerator and denominator for the calculation of rates and ratios Identify potential associations between outcome and the factors being studied
Do stroke rates differ by geographical location? Does the prevalence rate of AIDS differ by geographical location?

Measures of Disease Frequency

Key Measures Prevalence
Point Prevalence Period Prevalence

Incidence
Cumulative Incidence Incidence Rate or Incidence Density

Prevalence
I. Point Prevalence
Number of cases of disease present in the population at a particular time Total population at that specified time Is expressed as:
Percentage No. diseased/1,000 population

Prevalence
I. Point Prevalence Is a snap shot of the disease frequency at a point in time Is the most common measure of prevalence Is often determined by cross-sectional surveys

Prevalence
II. Period Prevalence
Number of cases of disease present in the population over a period of time Total population over that period of time Is expressed as:
Percentage No. diseased/1,000 population

Prevalence
Example
Blood samples are taken from a herd of 173 dairy cows to assess the frequency of Neospora caninum infection 15 animals test positive Prevalence =15/173 = 0.09 (9%)

Measures of Disease Frequency

Key Measures Prevalence
Point Prevalence Period Prevalence

Incidence
Cumulative Incidence Incidence Rate or Incidence Density

Incidence
Is the number of new cases/events in a population over a specific period of time Example:
The incidence of AIDS in the Australian population was 178 in 2001
i.e. 178 new cases of AIDS were diagnosed in Australia in 2001

Incidence
There are 2 main ways incidence is reported:
I. II. Cumulative Incidence Incidence rate or incidence density

Incidence
I. Cumulative Incidence (CI) The proportion of individuals in a population who became diseased during the specified period of time CI = No. new cases of disease or events during time period Total population at risk at the beginning of the time period

Cumulative Incidence
Assumptions: Entire population at risk has been followed from the beginning of the study till the end All participants are at risk of the outcome of interest

Cumulative Incidence
Example 1: The daily incidence of chickenpox in first grade children at Cayon primary school during the 1998 epidemic was:
10 new cases per 100 children

If there were 200 children in the first grade, how many new cases would there be each day?

Cumulative Incidence
Example 2: 818 women had in vitro fertilization in Puerto Rico in the year 2000 80 developed a clinical pregnancy within one month of follow-up after the first embryo transfer procedure. The CI of pregnancy was? CI= 80/818
9.8 cases per hundred women on the program

Attack Rate
Is a type of cumulative incidence Is applied to a narrowly defined population observed for a limited period of time, such as during an epidemic Attack rate = No. new cases of illness during a specified time period Total population at risk during that specified period

Attack Rate - Example

The Ministry of Health was called in to investigate more than 20 reports of people being ill with gastroenteritis after eating at a large restaurant in Frigate Bay during the first week of April 2009 An investigation was conducted by interviewing all patrons who ate at the restaurant during that week They found 2000 patrons ate at the restaurant that week and 400 became sick. What was the attack rate? Attack rate = = 400/2000 20 ill per 100 patrons

Incidence
II. Incidence Rate (IR) The incidence rate or incidence density is the number of new cases in a population divided by the total time units each individual in the population at risk was observed IR = No. new cases of disease or events during time period Sum of the length of time during which each individual in the population is at risk

Incidence Rate - Example

In investigating the incidence of duodenal ulcer following the use of a specific drug in 14 subjects: 4 subjects started the study in Jan 1990, all of whom finished the study in Dec 1999 10 subjects joined the study in Dec 1995 and finished the study in Nov 1996 After the period of observation: 5 people developed duodenal ulcer while taking the drug

Incidence Rate - Example

What is total length of time that persons in the population were at risk (denominator)?
4 X 10 years = 40 years 10 x 1 year = 10 years Total = 50 person-years New cases = 5 What is the incidence rate of duodenal ulcers after taking the drug? Incidence rate = 5 cases / 50 person-years = 10 cases per 100 person-years

Follow-up Period
Jan 1995 July 1995 Jan 1996 July 1996 Jan 1997

Duration of individual follow-up

Subjects A B C D E
X Total person years at risk X 1.0

1.5

1.0

2.0

0.5

Zero Time

6.0

Follow-up period

Development of disease X

Incidence Rate
Can be presented in many different ways:
10 cases/1000 person-years 1 case/100 person-years 0.1 cases/10 person-years 0.01 cases/1 person-year

These are all equivalent!

Incidence

Mortality Rate
The incidence of death Example: All-cause mortality rate for the Australian population 2001 = No. deaths during 2001 Total population in Australia at midyear 2001

Mortality Rate
Example: If there were 50,000 deaths in one year and 20,000,000 people living in Australia, what would be the mortality rate for Australia in that year? Mortality rate = 50,000 deaths/20 million = 2.5 deaths per 1000 pop = 250 deaths per 100,000 pop

Cause-Specific Mortality Rate

Mortality rate due to a specific disease or event Example:
Annual Mortality Rate for Lung Cancer per 1,000 population = No. new deaths from lung cancer per year x 1000 No. of persons in the population at mid year

Mortality Rate - Example

We can place restrictions on more than one characteristic simultaneously e.g. age and cause of death: No. new deaths from leukemia per year in children under 10 years No. of children under 10 years in the population at mid-year X 1,000 Note: Time must be specified in a mortality rate Mortality can be calculated over 1 year, 5 years, or longer

Case Fatality Rate

No of individuals dying during a specified period of time after disease onset or diagnosis Total number of individuals with the disease during that specified period

Example
Assume a population of 100,000 people of whom 20 are sick with disease X in 1999. In that same year, 18 die from the disease. What is the mortality rate?

What is the case-fatality rate?

A quick recap
An incident case of disease
A new case

A prevalent case
An existing case

Relationship between Incidence and Prevalence

An incident case becomes a prevalent case and remains a prevalent case until recovery or death Where a population is in a steady state, prevalence depends on incidence and duration of disease Thus prevalence of a disease may increase when incidence remains stable but survival of cases improves

Relationship between Incidence and Prevalence

In a steady-state population, prevalence depends on:
Incidence of illness Duration of illness

The relationship can be can be expressed as follows: Point prevalence Incidence density = x Duration of condition

Factors influencing prevalence rate

Increased by: -longer duration of disease -prolongation of life without cure -increase in new cases -in-migration of cases -out migration of healthy people -improved diagnosis Decreased by: -short duration of disease -high casefatality rate from disease -decrease in new cases -in-migration of healthy people -out-migration of cases -improved cure rate

Prevalence

Incidence and Prevalence

Incidence is generally used for acutely acquired diseases, prevalence is used for more permanent states, conditions or attributes of ill-health Incidence is more important when thinking of the etiology of the disorder, prevalence when thinking of societal burden of the disorder including the costs and resources consumed as a result of the disorder Incidence always requires a duration, prevalence may or may not

Incidence and Prevalence

Incidence generally requires an initial diseasefree interval before counting starts, because incidence is measured only in those at-risk of disease If one wishes to look at a change in disease (e.g. studies of causality, acute conditions or events, outbreak investigation) use incidence. For example:
Looking at the change in the incidence of cancer is important to know whether current prevention, screening and treatment activities are working

Diabetes Prevalence, US (CDC)

Trends in Diabetes Prevalence, US (CDC)

Recap
Prevalence Incidence Mortality rate Case-fatality rate

References
Epidemiology (2nd Ed), L. Gordis Essentials of Infectious Disease Epidemiology, M. Magnus Dr. N. Paneth