Basic measurements in Epidemiology

Measures of frequency,
Disease occurrence/Morbidity and Mortality

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 Objectives:
• After completing this chapter, the student will be able to:
 To define, calculate and differentiate Number, ratio,
proportion, and rate and understand their practical applications
and interpretations.

 To calculate and interpret measures of morbidity such as

incidence and prevalence rates

 To calculate and interpret measures of mortality such as crude,

specific rates and perform Standardization of rates.

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 Why Do We Measure Disease Frequency ?

 Fundamental to epidemiology:
♦ Distribution of disease and to make comparisons
♦ Monitoring the health status of the population and planning
health services

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 Tools in Measures of frequency

♦ Counts
♦ Ratio
♦ Proportion
♦ Rate

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 Counts

♦ Common descriptive measure

♦ First step in calculating rates
♦ Essential for service delivery, planning
♦ It is simple counting of cases of a disease

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 Ratio
• Used to compare two quantities.
• It expresses the relationship between two numbers in the form
of X: Y or X/Y
• The value of X and Y may be completely independent, or x
may be included in y.
Commonly used ratios:
♦ Ratio of male to female births (Male : Female)
♦ Age dependency ratio
♦ Maternal mortality ratio
♦ The ratio of people with tuberculosis to those without
tuberculosis

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 Proportion

♦ A specific type of ratio in which the numerator (X) is

included in the denominator (Y), usually presented as a
percentage.
Examples:
- Male/Both sexes (proportion of male in a community)
- Number of infants who are immunized in E/Wollega =
Total eligible infants for immunization in E/ Wollega
55,000
 73.3%
75,000

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 Rate
♦ Special form of proportion that includes a specification of
time.
♦ Rates are often proportions.
♦ Rates must:
1) include persons in the denominator who reflect the population
from which the cases in the numerator arose;
2) include counts in the numerator which are for the same time
period as those from the denominator; and
3) include only persons in the denominator who are "at risk" for
the event.
• Example: Measles cases in under five in 2015
Under five children in 2015

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 Summary

 All rates are proportions!

 All rates are ratios too!

 All proportions are ratios!

 But all proportions are not rates!

 All ratios are not proportions!

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 Table1.1 Neonatal sepsis, Hospital A,
Ethiopia, 2003

20-Feb-21 BY Tadesse T (BSc, MPH in 10

Epid), Nekemte, 2019
 Exercise 1/Home take 1
The line listing in the Table 1.1 presents some of
the information collected on infants born at
Hospital A with neonatal sepsis.
1. What is the ratio of males to females?
2. What proportion of infants lived?
3. What rate of infants were delivered in a delivery
room?
4. What is the ratio of operating room deliveries to
delivery room deliveries?

20-Feb-21 BY Tadesse T (BSc, MPH in 11

Epid), Nekemte, 2019
 Measures of Morbidity/disease occurrence

1. Prevalence
– burden

2. Incidence
– risk

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 Prevalence
• Measures the number of people in a population who have the
disease at a given point/period in time.
• A measure of disease status/disease burden.

Types of Prevalence:
a. Point Prevalence: number of cases that exist at a given point
in time.
b. Period Prevalence: number of cases that exist in a population
during a specified period of time.

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• The “Point in time” at which prevalence is determined may
refer to any of several time scales. Examples:
 Calendar time – e.g., prevalence of HIV infections in
Nekemte on January 1, 2005.

 Time since some event – e.g., prevalence of depression

among widows/widowers 6 months after the death of a
spouse.

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 Example
Two surveys were done in the same community 12 months
apart. Of 5,000 people surveyed the first time, 25 had
antibodies to histoplasmosis. Twelve months later, 35 had
antibodies, including the original 25. Calculate the prevalence
at the second survey, and compare the prevalence with the
1-year incidence.
1. Prevalence at the second survey:
x = antibody positive at second survey = 35
y = population = 5,000
x/y X10n = 35/5,000 x 1,000 = 7 per 1,000
2. Incidence during the 12-month period:
x = number of new positives during the 12-month period = 35 - 25 = 10
y = population at risk = 5,000 - 25 = 4,975
x/y x10n = 10/4,975 x1,000 = 2 per 1,000

BY Tadesse T (BSc, MPH in Epid),

20-Feb-21 15
Nekemte, 2019
 Factors Affecting Prevalence
Decreased by:
-Shorter duration of
disease
Increased by:
-High case-fatality rate
-Longer duration of the disease
from disease
-Decrease in new cases
-Prolongation of life of
(decrease in incidence)
patients without cure
-In-migration of healthy
-Increase in new cases
people
(increase in incidence)
-Out-migration of cases
-In-migration of cases
-Improved cure rate of
cases
-Out-migration of healthy people

-In-migration of susceptible people

-Improved diagnostic facilities

(better reporting)
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 Incidence
• Quantifies number of new cases of disease that develop in
a population at risk during a specified time period.

 Two types of populations, based on whether membership

is permanent or transient:
– Fixed population: membership is permanent
– Dynamic population: membership is transient

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 Incidence: Types

a. Cumulative Incidence (CI)

- Incidence proportion
- Closed population

b. Incidence Density (ID)

- Incidence Rate (IR)
- Dynamic and closed population

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 Cumulative Incidence (CI)
o The proportion of a closed population at risk that becomes
diseased within a given period of time.
o Is an estimate of average risk.

CI = No. of new cases of disease during a given period

Total population at risk during the given period

Example: During a 1-year period, 10 out of 100

“at risk” persons develop the disease of interest.

CI = 10/100 = 0.10 or 10.0 cases of disease per 100

population at risk
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 Cumulative incidence

Incidence proportion (IP). During a 2-year period, 3 out of 5

subjects developed the disease; IP = 3/5 = 0.6
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 Cumulative Incidence (CI)
o To accurately calculate cumulative incidence, we need to follow
the entire population for the specified time interval. Often
times, this does not fully occur.

o Cumulative incidence provides an estimate of the probability

(risk) that an individual will develop a disease during a specified
period of time.

 Over any appreciable period of time, it is usually technically

impossible to measure risk.

 This is because if a population is followed over a period of time,

some people in the population will die from causes other than
the outcome under study.

 The phenomenon of being removed from a study through death

or 20,
February 2021 other causes is referred to as ”competing risks”.
from 21
 Exercise
• On January 1, 2000 there were 20 medical students with
Influenza A and there were a total of 600 students in the class.
These 20 students were immune from contracting Influenza A
again during the next nine months. From January 2, 2000
through April 2, 2000, 30 more students developed Influenza
A and the class size remained at 600.

a. What was the prevalence of Influenza A on January 1, 2000?

b. What was the period prevalence of influenza A?
c. What was the cumulative incidence of Influenza A from
January 2, 2000 through April 2, 2000?

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 Incidence Density (ID)

o Other things being equal, the number of disease events

observed in a population over times varies directly with the
number of people at risk and the amount of time over which
they are observed.

ID = No. new cases of disease during a given period

Total “person-time” of observation

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 Incidence density…

• Often you can't follow everyone for entire time period.

• In a dynamic population, individuals enter population
over different times, become lost, etc.
• length of follow-up is not uniform for all .
• Incidence rates do not make assumption of complete
follow-up.

Since the number of cases is divided by a measure of time of

observation, rather than people, this helps address the
problem of competing risks.

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 Person-Time
Jan Jan Jan
1980 1989 1999

Subject 1 ------------------x 10 Person-Years (PY)

Subject 2 ------------------x 10 PY

Subject 3 ------------------------------------ 20 PY
40 PY

X = outcome of interest, thus the incident rate

is 2/40 PY
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 Ex. Cohort study of the risk of breast
cancer among women with
hyperthyroidism
 Followed 1,762 women ---> 30,324 py

 Average of 17 years of follow-up per

woman

 Ascertained 61 cases of breast cancer

 Incidence rate = 61/30,324 py =

.00201/py
February 20, 2021
= 201/100,000 py 26
 Special Types of Incidence: Attack Rate
o Variant of cumulative incidence
 Narrowly defined population
 Observed for a limited time (e.g. epidemic).
o Usually expressed as a percent.

Attack rate = Number of new cases among the

population during the period x 100
Population at risk at the
beginning of the period

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 Attack Rate: Example

• Of 75 persons who attended a church picnic, 46 subsequently

developed gastroenteritis.
a) Calculate the attack rate of gastroenteritis :
x = Cases of gastroenteritis occurring within the incubation period
for gastroenteritis among persons who attended the picnic = 46
y = Number of persons at the picnic = 75
AR= 46/75 x 100%

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 Special Types of Incidence:
Secondary Attack Rate
o A measure of the frequency of new cases of a disease among the
contacts of known cases. The formula is as follows:
o Secondary attack rate =Number of cases among contacts of
primary cases during the period x100
total number of contacts

To calculate the total number of household contacts,

Subtract the number of primary cases from the
total number of people residing in those households.
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 Secondary Attack Rate: Example
• Seven cases of hepatitis A occurred among 70 children attending
a child care center. Each infected child came from a different
family. The total number of persons in the 7 affected families was
32. One incubation period later, 5 family members of the 7
infected children also developed hepatitis A.
– Calculate the attack rate in the child care center and the
secondary attack rate among family contacts of those cases.

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February 20, 2021 31
Relationship of Incidence to
Prevalence
• Prevalence depends on both incidence rate and
duration of disease

Prevalence = Incidence X Duration

• Because prevalence is affected by factors such

as migration and duration,

 incidence is preferred for studying etiology.

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 Relationship between Incidence,
Prevalence and Disease Duration

Incidence

Deaths,
Prevalence
Cure,
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Lost to follow up
Measures of Mortality
Rates

• Crude rates

• Specific rates

• Standard (adjusted) rates

(assignment)
CRUDE RATES
• In epidemiologic research, population data are used
to examine and compare statistics on disease
incidence, prevalence and mortality.

• Crude rates are summary rates based on the actual

number of events( births, deaths, diseases) in a total
population over a given period time.

• Crude rates apply to the total population of a given

area. It is a rate that applies to the population as a
whole
 Crude rate ….

• Crude rate reflects the actual experience of a

population and should always be examined
when assessing the morbidity or mortality of a
population.

• The crude rates that are widely used in the

description of populations are CBR and CDR.
Advantages:
• Actual summary rate

• Useful for getting an overall picture of the amount of

disease in an area

• Calculable from minimum information

• Widely used despite limitations.

Disadvantages
• Difficult to interpret due to variation in composition(e.g.
age)

• Masks significant differences in risk between

SPECIFIC RATES

• Crude rates can be misleading if comparisons are being

made across groups or over time.

• When comparing crude rates for two population groups, the

groups may differ with respect to certain underlying
characteristics such as age.

• For example, a population with a higher proportion of

elderly people will have a higher overall crude death rate as
well as higher mortality for most chronic conditions because
the risk of dying is greater with increasing age. That is,
increasing age is a risk factor for death.
 Specific rates….
• One method used to account for differences in the
distribution of a risk factor across populations is
stratification followed by analysis of the stratum-specific
rates.

• Specific rates apply to specific subgroups in the

population (such as by age, sex, or occupation) or specific
diseases.

• When numerator and denominator are precisely available,

age and sex specific rates can be calculated and
compared between times, places, and population groups.

• The commonest and most important stratum-specific rate

 Specific rates….
• Age specific rates are calculated as the number of events over a
given time period in a specific age group divided by the population
in that age group over the same time period, typically expressed
as per 1000 or 100,000 population per year.

• The comparison of age-specific rates is the most comprehensive

and reliable method of comparing rates over time or between
population groups.

• Specific rates do not add up to a crude rates.

– One does not add age specific rates to get crude rate, but
rather takes the weighted average.

• Examples: IMR,NMR,MMR
Examples of Specific rates: IMR,NMR,MMR
• Maternal, infant, and childhood mortality have been
monitored in many parts of the world and they are often
considered strong indicators of general health.
IMR = Deaths of children under one year of age x 1000
Total live births

NMR= Deaths of children under 28 days of age x 1000

Total live births

MMR= Deaths of Mothers due to

maternal causes in a year X 100,000
Total live births in the same year
 Many Thanks!

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