Mindanao State University

COLLEGE OF MEDICINE
Department of Family and Community Medicine

HEALTH INDICES
Manuscript

Fatimah Akmilah Acraman

Ronnah Lynn J. Gerundio
Dianne P. Jagonia

Group 4 Clerks
Class of 2022

April 20, 2022

 Measures of Disease Frequency

Measures of disease frequency involve the concepts of prevalence and incidence. An

important factor in calculating these measures is the correct estimate of the numbers of
people under study or the population at risk. (Bonita et. al., 2006)
Populations at risk are people who are susceptible to a given disease and can be
defined by demographic, geographic, or environmental factors. An example is: Occupational
injuries occur only among working people, so the population at risk is the workforce. (Bonita et.
al., 2006).
Prevalence and incidence are frequently confused. Incidence measures the occurrence
of new disease, and prevalence measures the existence of current disease. Each measure
describes an important part of the natural course of a disease. Incidence deals with the
transition from health to disease, and prevalence focuses on the period of time that a person
lives with a disease. (Aschengrau et. al., 2018)

Figure Source: WHO Basic Epidemiology, Chapter 2.

A. Prevalence
Prevalence measures the frequency of existing disease over a specified time.
(Aschengrau et. al., 2018). It differs from incidence as it includes all cases, both new and pre-
existing, in the population at the specified time, whereas incidence is limited to new cases only
(Bonita et. al., 2006).
There are two types of prevalence: point prevalence and period prevalence.
● Point prevalence refers to the prevalence measured at a particular point in
time. It is the proportion of persons with a particular disease or attribute on a
particular date (Bonita et. al., 2006). The point can be either a particular
calendar date such as July 1, 2017, or a point in someone’s life, such as college
graduation (Aschengrau et. al., 2018).
 ● Period prevalence refers to prevalence measured over an interval of time. It is
the proportion of persons with a particular disease or attribute at any time
during the interval. The time interval or period referred to may be arbitrarily
selected, such as a month, a single calendar year, or a 5-year period. (Celentano
et. al., 2018)

Figure adapted from Aschengrau, A., & Seage, G. R. (2018). Essentials of Epidemiology in Public
Health (4th ed.). This shows the difference of point in time and period of time.

The value of 10n is usually 1 or 100 for common attributes. The value of 10n might be
1,000, 100,000, or even 1,000,000 for rare attributes and for most diseases.

Table adapted from Bonita, R., Beaglehole, R., & Kjellström, T. (2006). Basic Epidemiology (2nd ed.). WHO. This
shows the various factors that influence prevalence.

B. Incidence
 Incidence is the occurrence of new cases of disease that develop in a population at risk
over a specified time period (Aschengrau et. al., 2018). It considers the variable time periods
during which individuals are disease-free and thus “at risk” of developing the disease (Bonita
et. al., 2006).
There are two types of incidence: cumulative incidence and incidence rate.
● Cumulative incidence is defined as the proportion of a population at risk that
becomes diseased over a specified period of time (Aschengrau et. al., 2018).
Cumulative incidence is often presented as cases per 1000 population and the
period can be of any length but is usually several years, or even the whole
lifetime.

● Incidence rate is defined as the occurrence of new cases of disease that arise
during person-time of observation (Aschengrau et. al., 2018). Also known as
person-time rate, it is the ratio of the number of cases to the total time the
population is at risk of disease (CDC, 2006). It is a measure of the number of
new cases per unit of time.
● The critical element in defining incidence rate is new cases of disease. It is a
measure of events—the disease is identified in a person who develops the
disease and did not have the disease previously. Because the incidence rate is a
measure of events (i.e., transition from a non-diseased to a diseased state), the
incidence rate is a measure of risk. This risk can be looked at in any population
group, such as a particular age group, among males or females, in an
occupational group, or a group that has been exposed to a certain
environmental agent, such as radiation or a chemical toxin. (Aschengrau et. al.,
2018)

● Person-time is the amount of time that an at-risk person is under observation in

an epidemiological setting (CDC, 2006). The denominator, which is the person-
time data, is the sum of the time each person was observed, totaled for all
persons. For example: One person followed for 5 years without developing
disease is said to contribute 5 person-years of follow-up. For persons lost to
follow-up were assumed by researchers, on average, as disease-free for half the
year, and thus contribute ½ or 0.5 year to the denominator. (CDC, 2006) The 4
endpoints of person-time rate are the onset of disease, death, migration, and
end of study.

Vital Statistical Rates & Ratios

A. Natality Rates
Natality measures are population-based measures of birth. These measures are used
primarily by persons working in the field of maternal and child health. (CDC, 2006)

● Crude Birth Rate (CBR)

○ Crude birth rate is the ratio of the number of births during a specified period
(e.g., one year) to the total number of persons in the mid-period population or
July 1 of the same year (PSA). While it is a basic measure of fertility, it is only
occasionally used as a public health measure because there are other fertility
measures that are more population-at-risk specific and more comparable
across time and geography, such as the general fertility rate and the total
fertility rate. The reason the CBR is “crude” is because the total population is
represented in the denominator, similar to the crude death rate for example.
(New Jersey Department of Health)

● General Fertility Rate (GFR)

○ General fertility rate is the number of live births per 1,000 women aged 15-49
in a given year (PSA). It is the most commonly used fertility measure because it
matches often readily available numerator and denominator data in a broad age
range that covers most of the female reproductive years and thus represents
the population at greatest risk of giving birth. The numerator includes all live
births and not just those that occurred to women aged 15 through 44 years of
age. (New Jersey Department of Health)

B. Fertility Rates
Measures of fertility are particularly useful in planning maternal and child health
services.They are indispensable when approaching population control problems. These
measures also help school boards plan their future needs for facilities and teachers.The two
most common measures of fertility are the crude birth rate and the general fertility rate

Crude rates are computed for an entire population. They disregard differences that
usually exist by age, sex, race, or some category of disease.

● CBR, GFR
○ The crude birth rate, although quite commonly used, is a none-too-
sensitive measure of fertility because its denominator includes both
men and women. Strictly speaking, this measure cannot be a rate
because only a fraction of the population is capable of bearing children.
A more sensitive measure is the general fertility rate.
● General Fertility Rate
○ Defined as the number of live births in a calendar year, divided by the
number of women ages 15-44 at midyear, the quotient being multiplied
by 1000.
○ Also known as crude fertility rate. This rate is more sensitive than the
crude birth rate because its denominator includes only women of child-
bearing age.

● Age-specific Fertility Rates

○ The number of births to women of a given age group per 1,000
women in that age group. It is calculated by dividing the number of
births to women of a particular age group by the female population in
that age group multiplied by 1,000.

= 54.800
54.8 or 55 live births for the age group 35-39 years old.

● Total Fertility Rate

 ○ The average number of children that would be born alive to a woman (or
group of women) during her lifetime if she were to pass through her
childbearing years conforming to the age specific fertility rates of a
given time period. Refers to the number of children a woman would
have by the time she reaches age 50 under a given fixed fertility
schedule.
○ It is sometimes referred to as completed family size.

● Gross Reproduction Rate

○ According to the UN, “The average number of daughters that would be
born alive to a woman (or group of women) during her lifetime if she
passed through her childbearing years conforming to the age-specific
fertility rates of a given year.”
○ The gross reproduction rate relates the fertility rate to female births
only. It is defined as the number of girls which are expected to be born
to 1000 females passing through their child bearing years.
○ This rate is a measure of replacement fertility if mortality is not in the
equation. It is often regarded as the extent to which the generation of
daughters replaces the preceding generation of women and so on and
so forth.

○ If the value is equal to one that indicates that women will replace themselves.
 ○ If the value is more than one that indicates that the next generation of women
will outnumber the current one.
○ If the value is less than one, that indicates that the next generation of women
will be less numerous than the current one.

C. Mortality Rates
Expressing mortality in quantitative terms can pinpoint differences in the risk of dying
from a disease between people in different geographic areas and subgroups in the population.
Mortality rates can serve as measures of disease severity, and can help us to determine
whether the treatment for a disease has become more effective over time.
In addition, given the problem that often arises in identifying new cases of a disease,
mortality rates may serve as surrogates for incidence rates when the disease being studied is a
severe and lethal one. Each rate is a measure of the relative frequency of deaths that occurred
in a given population over a specific period.

● It is a measure of the frequency of occurrence of death in a defined population during a

specified interval.
● In the mortality rate, the denominator represents the entire population at risk of dying
from the disease, including both those who have the disease and those who do not have
the disease (but who are at risk of developing the disease) for a mortality rate to make
sense, anyone in the group represented by the denominator must have the potential to
enter the group represented by the numerator (Gordis).

When mortality rates are based on vital statistics (e.g., counts of death certificates), the
denominator most commonly used is the size of the population at the middle of the time
period. In the United States, values of 1,000 and 100,000 are both used for 10n for most types
of mortality rates. The table summarizes the formulas of frequently used mortality measures.
● Crude Death Rate
○ It is the ratio of the number of deaths from all causes occurring within
one year to the mid-year population expressed per 1,000 population
which may result in a decrease of population (PHS)
○ It is "crude" in the sense that all ages are represented in the rate and
does not take into account the variations in risks of dying at particular
ages. It is indeed crude—a generalized indicator of the health of a
population
 = 5.78 or 5.8 Deaths per 1000
population per year

● Age-specific Mortality Rate

○ Specific rates consider the differences among subgroups and are
computed by age, race, sex, or other variables. Age-specific Death Rate
is defined as the number of deaths in a specific age group in a calendar
year, divided by the population of the same age group on July 1 of that
year, the quotient being multiplied by 1000.

Age-specific Mortality Rate= 0.7719 or 0.8 per 1000 population per year for age group 15-19
● Cause-specific Mortality Rate
○ Defined as the number of deaths assigned to a specific cause in a
calendar year, divided by the population on July 1 of that year, the
quotient being multiplied by 100,000.

= 60.4 deaths for 100,000 population per year due to

Malignant neoplasms

● Mortality Rates in Children

○ Infant Mortality Rate
■ The probability of dying between birth and age one, expressed
as the number of infant deaths or deaths occurring before
reaching 12 months of life in a given period per 1,000 live births.
Measures the risk of dying during the 1st year of life. The infant
mortality rate is perhaps the most commonly used measure for
comparing health status among nations.

- It is a widely used measure of health status because it reflects the health

of the mother and infant during pregnancy and the year thereafter.
 - The health of the mother and infant, in turn, reflects a wide variety of
factors, including access to prenatal care, prevalence of prenatal
maternal health behaviors (such as alcohol or tobacco use and proper
nutrition during pregnancy, etc.), postnatal care and behaviors
(including childhood immunizations and proper nutrition), sanitation,
and infection control.

○ It is a good index of the general health condition of a community since it

reflects the changes in the environmental and medical conditions of a
community. The infant mortality rate is generally calculated on an
annual basis.
○ Is the infant mortality rate a ratio? Yes.
○ Is it a proportion? No, because some of the deaths in the numerator
were among children born the previous year
○ Is the infant mortality rate truly a rate? No, because the denominator is
not the size of the mid-year population of children < 1 year of age.

= 11.9 Infant deaths per 1,000 population in 2017

● Perinatal Mortality Rate

○ According to the World Health Organization, a perinatal death can
either be a live birth or a stillbirth and formally covers the period from
22 completed weeks of gestation up to 7 days after birth.
○ Perinatal Mortality Rate is the number of deaths of fetuses weighing at
least 500g (or, when birth weight is unavailable, after 22 completed
weeks of gestation or with a crown-heel length of 25 cm or more), and
early neonatal deaths (Number of infant deaths under age 7 days), per
1000 total births.
Because of the different denominators in each component, this is not
necessarily equal to the sum of the fetal death rate and the early neonatal mortality
rate.
● Neonatal Mortality Rate
○ NEONATAL DEATH – is the death among live births during the first 28
completed days of life.
○ NEONATAL DEATH RATE (NDR) - Measures the risk of dying during the
1st month of life. May serve as an index of the effects of prenatal care
and obstetrical management on the newborn.

Neonatal Death (2019)= 9000 (example)

= 5.37 or 5.4 Neonatal Deaths per 1,000 live births per

year

● Post-neonatal Mortality Rate

○ The postneonatal period is defined as the period from 28 days of age up
to but not including 1 year of age. The numerator of the postneonatal
mortality rate therefore is the number of deaths among children from
28 days up to but not including 1 year of age during a given time period.
○ The denominator is the number of live births reported during the same
time period. The postneonatal mortality rate is usually expressed per
1,000 live births.
 Postneonatal mortality rate= 7.60 postneonatal deaths per 1000 live births per year

● Child Mortality Rate

○ CMR in WHO, is the Under Five Mortality Rate (U5MR): the probability
of dying between birth and age five, expressed as the number of deaths
below age five per 1,000 live births during a given period.
○ Under-five mortality rate as defined here is strictly speaking not a rate
(i.e. the number of deaths divided by the number of population at risk
during a certain period of time) but a probability of death derived from a
life table and expressed as rate per 1000 live births. Under-five
mortality rate measures child survival. It also reflects the social,
economic and environmental conditions in which children (and others in
society) live, including their health care. Because data on the incidences
and prevalence of diseases (morbidity data) frequently are unavailable,
mortality rates are often used to identify vulnerable populations.
Under-five mortality rate is an MDG indicator.
○ The probability of dying between exact age one and age five, expressed
as the number of deaths of children from exact age one to less than age
five during a given period per 1,000 children surviving to age 12 months
at the beginning of the period

CMR= 5.58 deaths of children age 1 to 4 per 1000 children aged 12 months at the beginning of
the period per year
● Maternal Mortality Rate
○ The maternal mortality rate is really a ratio used to measure mortality
associated with pregnancy. It refers to the risk of mothers dying from
causes associated with delivering babies, complications of pregnancy or
childbirth.

■ DIRECT MMR: Direct obstetric deaths (or direct maternal

deaths) are those “resulting from obstetric complications of the
pregnant state (pregnancy, labour and puerperium), and from
interventions, omissions, incorrect treatment, or from a chain of
events resulting from any of the above”. Deaths due to obstetric
haemorrhage or hypertensive disorders in pregnancy, for
example, or those due to complications of anaesthesia or
caesarean section are classified as direct maternal deaths.
■ INDIRECT MMR: Indirect obstetric deaths (or indirect maternal
deaths) are those maternal deaths “resulting from previous
existing disease or disease that developed during pregnancy and
not due to direct obstetric causes but were aggravated by the
physiologic effects of pregnancy”. For example, deaths due to
aggravation (by pregnancy) of an existing cardiac or renal
disease are considered indirect maternal deaths.

● Proportionate Mortality Rate

○ Proportionate mortality describes the proportion of deaths in a
specified population over a period of time attributable to different
causes. Each cause is expressed as a percentage of all deaths, and the
sum of the causes must add to 100%. These proportions are not
mortality rates, because the denominator is all deaths rather than the
population in which the deaths occurred.

● Case Fatality Rate

○ The case-fatality rate is the proportion of persons with a
particular condition (cases) who die from that condition. It is a
measure of the severity of the condition. The case-fatality rate is
a proportion, so the numerator is restricted to deaths among
people included in the denominator.
 ● Swaroop’s Index
○ Swaroop’s index represents the proportion of deaths among
people aged 50 years and over for every 100 total deaths (a
higher value indicates a better health situation).

○ This is a good indicator in comparing the health status of

different countries, since it is very simple and most of the
information needed is available. The higher the rate the better is
the health status of the population.

Civil Registry and Vital Statistics

A. Civil Registration
● Civil registration is defined as the continuous, permanent, compulsory and
universal recording of the occurrence and characteristics of vital events
pertaining to the population as provided through decree or regulation in
accordance with the legal requirements of each country.
● It is carried out primarily for the purpose of establishing the legal documents
provided by law. These records are also the best source of vital statistics.
● The occurrences considered as vital events are live birth, death, fetal death,
marriage, divorce, annulment of marriage, judicial separation of marriage,
adoption, legitimation and recognition.
● Civil registration is an ideal source of statistics on important demographic
processes such as fertility, mortality and nuptiality, which in turn, are the basic
information needed for monitoring population growth.

B. Birth Certificate
● The permanent and official recording of a child’s existence
● As legal documents: Certificate of Birth and Certificate of Live Birth
● Article 7 of the Convention on the Rights of the Child states that:
The child shall be registered immediately after birth and shall have the right from birth
to a name, the right to acquire a nationality, and as far as possible, the right to know and
be cared for by his/her parents

What to register?
All those born alive shall be registered as qualified by the following definition:
 ● Live birth: complete expulsion or extraction of a product of conception from its
mother irrespective of the duration of the pregnancy, which after such
separation, breathes or shows any evidence of life, such as beating of the heart,
pulsation of the umbilical cord, or definite movement of voluntary muscles,
whether or not the umbilical cord has been cut or the placenta is attached
● A fetus with an intrauterine life of 7 months or more and born alive at the time
it was completely delivered from the maternal womb but died later shall be
considered as live birth and shall be registered in the Register of Births (Rule 18
pars 1 & 2 of Act 3753)
● If the fetus has an intrauterine life of less than 7 months, it is not deemed born if
it dies within 24 hours after its complete delivery from the maternal womb
(Article 41, RA 386). For statistical purposes, COLB and COD shall be prepared

Intrauterine life Fetus lived Fetus lived Remarks

<24 hrs >24hrs

< 7 months + Accomplish COLB and

COD with remarks “for
statistical purposes”

+ Accomplish COLB and

COD and register

7 months or more + + Accomplish COLB and

COD and register

Who is responsible for reporting the event and preparing the COLB?

Place of Occurence Who will report/prepare the COLB?

Born in the hospital or clinic
The administrator of the hospital, clinic, or similar
institution is responsible in preparing the COLB of the
child
The attendant at birth is responsible in certifying the
facts of birth
The administrator of the hospital, clinic, or similar
institution is responsible for causing the registration of
birth to the LCRO

Born outside the hospital, The physicians, nurses, midwives, and hilots or any
clinic, or at home person who attended the delivery of the child outside
the hospitals or clinics shall be responsible both in
certifying the facts of birth and causing the registration
 of birth to the LCRO

While on travel The bus driver or taxi driver, captain or pilot, and the
parents have the joint responsibility in causing the
registration of birth to the LCRO

For unattended births The parents or any responsible person has the duty to
cause the registration of the birth to the LCRO. The civil
registrar or his authorized staff shall prepare the COLB.

When and where to register?

● The birth of a child shall be registered within 30 days from the time of birth
in the Office of the Local Civil Registrar of the place where it occurred (Rule
8 (1), AO No. 1, as amended series of 1983).

C. Death Certificate
● The permanent and official recording of a person’s death
● As legal documents: Certificate of Death & Certificate of Fetal Death
● Act 3753, Section 6, Circular No. 4, Series of 1973 states that: No human body shall be
buried unless the proper death certificate has been presented and recorded in the
Office of the Local Civil Registrar.

What to register?
All persons who died shall be registered as qualified by the following definition:
● Death
○ The permanent disappearance of all evidence of life at any time after live birth
has taken place (postnatal cessation of vital functions without capability of
resuscitation)
○ Note: Body parts surgically removed are not considered as death of a person

● Fetal Death
○ Death prior to the complete expulsion or extraction from its mother of a
product of conception, irrespective of the duration of pregnancy.
○ Indicated by the fact that after such separation the fetus does not breathe or
show any other evidence of life, such as beating of the heart, pulsation of the
umbilical cord, or definite movement of voluntary muscle.

Who is responsible for reporting the event and preparing the COD or COFD?
● It shall be the responsibility of the physician who last attended the deceased or the
administrator of the hospital or clinic where the person died to prepare the
certificate of death and to certify as to the cause of death.
● The COD shall be forwarded within 48 h after death to the Local Health Officer who
shall examine the documents for completeness of entry, affix his/her signature in
the appropriate box of the certificate and direct its registration at the Office of the
Local Civil Registrar of the place of death.
● The responsibility of certifying the cause of death and fetal death devolves upon the
Local Health Officer (LHO) in the absence of medical attendance of the deceased.
● The mayor, any member of the SB, or the municipal secretary shall sign the medical
certification portion of the COD, and the same shall be accepted for registration by
the Civil Registrar, provided that the COD and the Register of Deaths shall carry a
remark that the registration was made pursuant to Section 91 of P.D. No. 856.
● There are special circumstances when the COD cannot be issued in time, in these
scenarios, the requirement for a COD before burial may be waived.
○ The person died from a dangerous communicable disease and must be
buried within 12 hours
○ The family members of deceased have requested immediate cremation
without embalming for viewing
○ The kin opt immediate burial
○ Religious beliefs or tradition, such as Islam or the Jewish calls for burial
within 12 hours after death
○ In these cases, death certificate issuance shall be completed within 12 hours
after burial and sanction shall be imposed by the Local Health Authority (AO
No. 2010-0033 the Revised IRR of PD 856, Chapter XXI “Disposal of Dead
Persons” issued by DOH)

When and where to register?

Death shall be registered within 30 days from the time of death in the Office of the
Local Civil Registrar of the place of occurrence
D. Vital Statistics Registry

● derived from information obtained at the time when the occurrences of vital events
and their characteristics are inscribed in a civil register.
● collecting by registration, enumeration or indirect estimation of information on the
frequency of occurrence of certain vital events, as well as relevant characteristics
of the events themselves and of the person(s) concerned
● compiling, analyzing, evaluating, presenting and disseminating those data in
statistical form.
● The PSA maintains an archive of Civil Registration documents. Several basic forms
are needed to record vital events from which vital statistics were generated. These
are:
○ Marriage Certificate – Municipal Form No. 101
○ Certificate of Live Birth – Municipal Form No. 102
○ Certificate of Death – Municipal Form No. 103
○ Certificate of Fetal Death – Municipal Form No. 103A

Uses of Vital Statistics Registry

Vital Statistics are useful for local and national authorities specifically for planning of
human, social and economic development.
They use the data results in the following:
● as input for population estimation/projection for future planning
● as basis for forecasting requirements for food, housing, medical facilities, education
and other needs of the population
● to carry out policy making at local levels for planning health, education services,
housing, etc.
● to address health inequities from communicable disease, chronic disease and
injuries
● generate “life tables” and life expectancies for many health-planning purposes
 ● measure progress on the sustainable development goals and other international
health goals
● prepare polling lists for eligible voters for election purposes
● calculate the number of members of parliament for each state or province
● allocate budgets for development and for human resources
● calculate the number of citizens each year for administrative areas by age and sex
● provide denominator data for calculating health-related indicators • help to guide
efficient resource allocation
● other analytical studies which are important and useful to planners and policy-
makers

E. Census
● Census is defined as the enumeration of an entire population, usually including
details on residence, age, sex, occupation, racial/ethnic group, marital status, birth
history, and relationship to the head of household. In our country, the Philippine
census is a regularly occurring and official inventory of the human population and
housing units in the Philippines.
● Aims to provide government executives, policy makers, and planners with
population and housing data on which to base their social and economic
developmental plans, policies, and programs
● The 2020 CPH is the 15th census in the Philippines (15th census of population and
7th census of housing) and is the second census conducted by the PSA.
● CPH or Census of Population and Housing is the decennial census conducted by
PSA.

References:
● 2020 CPH. Philippine Statistics Authority. (2020, January 10). Retrieved February 23,
2022, from https://psa.gov.ph/content/psa-enjoins-public-support-conduct-2020-
census-population-and-housing-cph-0
● Civil Registration and Vital Statistics Handbook for Health Workers, Second edition.
Philippine Statistics Authority
● Grande, M. B. (n.d.). What You Need To Know About Civil Registration? psa.gov.ph
● Principles of Epidemiology in Public Health Practice, Third Edition. An Introduction to
Applied Epidemiology and Biostatistics.
● Jekels Epidemiology, Biostatistics and Preventive Medicine & Public Health. Fourth
Edition
● Philippine Statistics Authority | Republic of the Philippines
● Primer on vital statistics, from http://rsso09.psa.gov.ph/sites/default/files/Primer
%20on%20Vital%20Statistics.pdf
● PSA Primer, from
http://cavitecity.gov.ph/index.php/component/phocadownload/category/48-census-
2020
● https://psa.gov.ph/content/child-mortality-rate-cmr-2
● https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4622
● Swaroop, S. & Uemura, K. (1957). Proportional mortality of 50 years and above. Bulletin of
the World Health Organization, 17 (3), 439 - 481.