Basic measurements in Epidemiology

By: Abdi Birhanu (MpH in Epidemiology)

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Learning objectives
After completing this session, students should be
able to:
• Describe the principles of measurement in
epidemiology
• Explain measures of disease frequency
• Calculate measure of disease occurrence
• Calculate measure of mortality

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Measurement of health
• Epidemiology is mainly a quantitative science.

• Measures of disease frequency are the basic tools of the

epidemiological approach.

• Health status of a community is assessed by the collection,

compilation, analysis and interpretation of data on illness
(morbidity), on death (mortality), disability and utilization
of health services.

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 The most basic measure of disease frequency is a simple
count of affected individuals/people with the event.
 Such information is useful for public health planners and
administrators for the allocation of health care resources in a
particular community.
 However, to investigate distributions and determinants of
disease, it is also necessary to know the size of the source
population from which affected individuals were counted.

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 One of the central concerns of epidemiology is to
find and enumerate appropriate denominators in
order to describe and to compare groups in a
meaningful and useful way.

 Such measures allow direct comparisons of

disease frequencies in two or more groups of
individuals.

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Measures of …..
….frequency Disease occurrence
– Count – Prevalence
– Ratio – Incidence
– Proportion • Cumulative incidence (
– Rate CI), (Incidence
proportion)
• Incidence density (ID),
• Attack rate (AR)

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I. Measuring Disease frequency
1. Number/counts:-Counting case, events, phenomena
• The number of cases in a given community can give
more epidemiologic sense if they are related to the size
of the population.
• 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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 Relating Counts to Population
• Requires calculating:
– Ratio
– Proportion
– Rate
• These measures provide useful information about the probability
of occurrence of health events, population at a higher risk of
acquiring the disease.

• They are also important in designing appropriate public health

interventions

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 2. Ratio
• Ratio: relating two completely independent
parameters
• A ratio is the relative size of two quantities
• It quantifies the magnitude of occurrence of
something in relation to another.
• One character divided by another
(the value of x and y are independent)
– Example:
• The ratio of males to females in Ethiopia
• The ratio of male to female birth in ‘X’ community

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 Conti…
• No specific relationship is necessary between the
numerator and denominator
• (numerator NOT necessarily included in the
denominator)
• Either the numerator or denominator is set to 1
• n:y or
• n/n: y/n or 1 to y/n

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 example
• # beds per doctor
120 beds/10 doctors
120/10 : 10/10
12 beds for a doctor
• Odds ratio
• Rate ratio
• Maternal mortality rate

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 3. Proportion
• Proportion:
– relating two dependent parameters
• It is a specific type of ratio in which the
numerator is included in the denominator and the
result is expressed as a percentage.
Example: proportion of female in a community
Female/ Female + male *100

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 It is comparison of a part to the whole
population
 Numerator MUST BE INCLUDED in the
denominator
 It’s result ranges between 0 and 1 or(0–100%)
 Parentage = Proportion x 100
Example
Population 3500 women and 6500 men
Proportion of men
= 6500 / (3500 + 6500) = 0.65 or 65 %
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4. RATE

• Rate is a special form of proportion that includes the

dimension of time.
• Rate: measures the occurrence of an event in a population
over time.
• It is the measure that most clearly expresses probability or
risk of disease in a defined population over a specified
period of time, it is considered to be a basic measure of
disease occurrence.
• Accurate count of all events of interest that occur in a
defined population during a specified period is essential
for the calculation of rate.
Rate = Number of events in a specific period X k
Pop. at risk of these events in a specified period

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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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 Types of rates

There are three types of rate:

• Crude rates
• Specific rates
• Adjusted rates
Read the advantage and disadvantage of these
rates

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 II. Measures of Disease Occurrence

1. Incidence

• The incidence of a disease is defined as the number of

new cases of a disease that occur during a specified
period of time in a population at risk for developing the
disease.

Incidence rate =Number of new cases of a disease over a period of time X 1000
Population at risk during the given period of time

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 CONT….

 The critical element in the definition of

incidence is new cases of disease.

 Because incidence is a measure of new

events (i.e. transition from a non-diseased to
a diseased state), incidence is a measure of
risk.

 The appropriate denominator for incidence

rate is population at risk.
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 For incidence to be meaningful, any
individual who is included in the
denominator must have the potential to
become part of the group that is counted in
the numerator.

 Thus, if we are calculating incidence for

Endometritis the denominator must include
only women , because men are not at risk for
developing Endometritis.

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 Cont…

• Another important issue in regard to the

denominator is the issue of time.
• For incidence to be a measure of risk we must
specify a period of time and we must know that
all of the individuals in the group represented by
the denominator have been followed up for that
entire period.
• The choice of time period is arbitrary:
• We could calculate incidence in one week,
incidence in one month, incidence in one year,
incidence in 5 years, and so on.

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 CONT…

Nevertheless the determination of population at risk is

a major problem in the study of disease incidences.
It may require a detailed study based on:

• Interviews
• medical records
• or serology for antibodies, which are very expensive
and time consuming.
• Population fluctuation due to births, deaths, and
migration is another problem in the calculation of the
denominator.
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 Types of incidence
1. Cumulative Incidence(CI)
An incidence rate which is calculated from a population
that is more or less stable (little fluctuation over the
interval considered), by taking the population at the
beginning of the time period as denominator.
The cumulative incidence assumes that the entire
population at risk at the beginning of the study period has
been followed for the specified time interval for the
development of the outcome under investigation.

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 It provides an estimate of the probability, or risk,
that an individual will develop a disease/event
during a specified period of time.
CI = Number of new cases of a disease during a given period of time X 1000
Total population at risk

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 Cumulative Incidence cont…

• Cumulative incidence relates occurrences of new

cases to the population in the follow up period

1000 persons How many

at risk people develop
the outcome?
What
Time 0 Time 1 proportion
develop the
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outcome? 24
 Cont…

2. Incidence density:
An incidence rate whose denominator is calculated using person-time
units.
Similar to other measure of incidence, the numerator of the incidence
density is the number of new cases in the population.
The denominator, however, is the sum of each individual’s time at
risk or the sum of the time that each person remained under
observation, i.e., person - time denominator.

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 CONT…

 This is particularly when one is studying a group

whose members are observed for different lengths of
time.

 In presenting incidence density, it is essential to specify

the time units - that is, whether the rate represents the
number of cases per person - day, person - month or
person - year.

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Incidence
density =Number of new cases during a given period x1000
sum of the time each person was observed

Incidence density is often used in study like cohort

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 Person Time
Person-time of follow-up should also not start until the individual is first at
risk. (If a group of workers is followed to assess work-related risks,
generation of person-time could not start before first employment).

1 2 3 4 5 6 7 8 9 10 11 12
Time in months
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Each line represents a duration of follow up.
 Example
No. people Period at risk Person-year
contribution
50 1 year 50

40 6 months 20

20 3 months 5

110 75

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Basic requirements for calculating incidence rates
1. Knowledge of the health status of the study population
2. Time of onset
• Since incidence rates deal with newly developing diseases,
identifying the date of onset is necessary.

3. Specification of numerator:

Number of persons versus number of conditions

Sometimes one person may have more than one episode of the
illness under study; therefore it is absolutely necessary to
indicate whether the numerator addresses number of
conditions or number of persons.

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 Cont…
• Example: children may have more than one
episode of diarrhea in a one-year period.
Hence, it is possible to construct two types
of incidence rates from this.

i. Number of children who developed diarrhea in one-year period X1000

Number of children at risk

ii. Number of episodes of diarrhea in children in one-year period X 1000

Number of children at risk

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 Cont…
4. Specification of denominator:

• The denominator for incidence studies should

consist of a defined population that is at risk of
developing the disease under consideration.

• It should not include those who have the

disease or those who are not susceptible to the
disease.

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 Cont…
5. Period of observation:

 Incidence rates must be stated in terms of a definite

period of time. It can be any length of time.

 The time has to be long enough to ensure stability of

the numerator. Person-time denominator must be
used for unequal periods of observation.

 This helps to weigh the contribution of each study

subjects when there is attrition because; individuals
die, move away or get lost to follow up.

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 PREVALENCE RATE

 The prevalence rate measures the number of

people in a population who have a disease at a
given time.
 It includes both new and old cases.
 Measures disease burden

There are two types of prevalence rates.

1. Point prevalence rate.

2. Period prevalence rate
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 CONT…

• Point prevalence rate measures the proportion of a population

with a certain condition at a given point in time.
• This is not a true rate; rather it is a simple proportion.

Point prevalence rate = condition at one point in time X 100

Total population

• Period prevalence rate measures the proportion of a population

that is affected with a certain condition during a specified
period of time.

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 No. of people with the condition
Period prevalence rate =during a specific period of time X100
Total population

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Generally prevalence:-
• It is simply defined as the proportion of the total
population that is diseased.
• Unlike the numerator for the two incidence
measures, the prevalence numerator includes all
currently living cases regardless of when they
first developed.
• Prevalence denominator includes everyone in
the population— sick, healthy, at risk, and not at
risk.

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 Relationship between incidence and prevalence

• Prevalence depends on the rate at which new

cases of disease develop (the incidence rate),
as well as the duration or length of time that
individuals have the disease.
• Mathematically, the relationship between
prevalence and incidence is as follows:
• prevalence rate ~ IR x D

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 Relationships: incidence, prevalence and duration

P≅ I · D

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 Illustrations of incidence and prevalence
Key
Key
Case 1
Start
- On setofofillness
illness
Case 2 Case 3 __Duration
- Duration ofof
illness
illness

Case 4
Case 5

Case 6

Case 8
Case 7
Dec, 31
Jan, 1
Incidence would include case 3,4, 5 and 8
Point prevalence (Jan1) case 1, 2 and 7
Point prevalence De. 31) Case 1, 3, 5 and 8
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Period prevalence( Jan -Dec) Cases, 1,2,3,4,5, 7 and 8
 Uses

Prevalence rates are important particularly for:

• Chronic disease studies
• Planning health facilities and manpower
• Monitoring disease control programs
• Tracing changes in disease patterns over time.

Incidence rates are important particularly for

• A fundamental tool for etiologic studies
• A direct measure of risk.

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Generally
 High prevalence may reflect an increase in survival
due to change in virulence or in host factors or
improvement in medical care or high incidence
 Low prevalence may reflect:
– A rapidly fatal process
– Rapid cure of disease
– Low incidence.

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 Factors influencing Prevalence

Increased By Decreased By
By longer duration of the disease Shorter duration of the disease

Prolongation of life of patients High case fatality

without cure
Decrease in new cases (decrease
Increase in new cases (increase in in incidence)
incidence)
In-migration of health people
In-migration of cases
Out-migration of cases
Out-migration of healthy people
Out-migration of susceptible people
In-migration of susceptible people
Improved cure rate of cases)
Improved diagnostic facilities
(better reporting)
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 Limitations of prevalence studies

• Prevalence studies favor inclusion of chronic

over acute cases

• Disease status and attribute are measured at the

same time; hence, temporal relations cannot be
established.

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 III. Measurements of Mortality
 Mortality rates and ratios measure the occurrence
of deaths in a population using different ways.

 Rates whose denominators are the total population

are commonly calculated using either the mid-
interval population or the average population.

 This is done because population size fluctuates

over time due to births, deaths and migration.

 Below are given some formulas for the commonly

used mortality rates and ratios.

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 Total no. of deaths reported
• Crude death rate (CDR) = during a given time interval X 1000
Estimated mid interval population

No. of deaths in a specific age

• Age-specific mortality rate =group during a given time X 1000
Estimated mid interval population of
specific age group

No. of deaths in a specific sex

• Sex-specific mortality rate = during a given time X 1000
Estimated mid interval population of same sex

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 No. of deaths from a specific cause
• Cause-specific mortality rate = during a given time X 100,000
Estimated mid interval population

No. of deaths from a sp. cause

• Proportionate mortality ratio = during a given time x 100
Total no. of deaths from all causes in the same time

No. of deaths from a sp. disease

• Case fatality rate (CFR) = during a given time x 100
No. of cases of that disease during the same time

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 No. of fetal deaths of 28 wks or more
Fetal death rate = gestation reported during a given time
No. of fetal deaths of 28 wks or more gestation
and live births in the same time

No. of fetal deaths of 28 wks or more gestation

Per natal Mortality Rate =. Plus no. of infant deaths under 7 days
No. of fetal deaths of 28 wks or more gestation
plus the no. of live births during the same time

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 No. of deaths under 28 days of age
Neonatal Mortality rate = reported during a given time x 1000
Number. of live births reported during the same
time

No. of deaths under 1 yr of age

Infant mortality rate (IMR) = during a given time X 1000
No. of live births reported during the
same time interval

No. of deaths of 1-4 yrs of age

Child mortality rate (CMR) = during a given time X 1000
Average (mid-interval) population of same
age at same time

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 No. of deaths of 0-4 yrs of age
Under- five mortality rate = during a given time X 1000
Average (mid-interval) population of the same
age at same time

No. of pregnancy associated deaths

Maternal mortality ratio = of mothers in a given time x 100,000
No. of live births in the same time

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Other commonly used indices of health

No. of live births reported

Crude Birth Rate (CBR) = during a time interval X 1000
Estimated mid-interval population

No. of live births reported during a

General fertility rate (GFR)= given time interval X 1000
Estimated no. of women 15-44
years of age at mid interval

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 No. of live births of weight less than
Proportion of LBW = 2500 gms during a given time x 100
No. of live births reported during the same
time interval

No. of new cases of a sp. disease

Attack rate = reported during an epidemic x k
Total population at risk during the same time

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• .

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