Epidemiology – Descriptive Epidemiology I

MA1610: Applied Epidemiology & Biostatistics

Part B: Epidemiology, Summer term 2017

DESCRIPTIVE EPIDEMIOLOGY I

PD Dr. Annika Waldmann

Epidemiology – Descriptive Epidemiology I

Qualification goals & competencies

Students should be able…

• To describe the key aspects of measuring disease
occurrence (case, population, time)
• To distinguish between a fixed and a dynamic population
• To define and distinguish between cumulative incidence,
incidence rate, and prevalence
• To critically appraise a paper on incidence and
prevalence

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 Epidemiology – Descriptive Epidemiology I

Practise of descriptive epidemiology

Characterise an epidemiologic event:

1. What = health issue of concern, case definition
2. Who = person
3. Where = place
4. When = time Descriptive epidemiology
5. Why/how = causes, risk factors, modes of transmission
Analytic epidemiology
Systematic approach:
Count – Divide – Compare

Epidemiology – Descriptive Epidemiology I

What is health?

WHO definition of health

Health is a state of complete physical, mental and social

well-being and not merely the absence of disease or
infirmity.

Bibliographic citation for this definition:

Preamble to the Constitution of WHO as adopted by the International Health
Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the
representatives of 61 States (Official Records of WHO, no. 2, p. 100) and
entered into force on 7 April 1948.
The definition has not been amended since 1948.

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 Epidemiology – Descriptive Epidemiology I

What is a disease / an illness?

• Often defined as the opposite of health, deviation
from a functional norm
• Diagnosis is based on: The ill child
Combination of symptoms (subjective), signs Edvard Munch

(objective indication), and additional tests

• “Paradox of Disease”:
Health status can be found abnormal – sometimes without a
subjective feeling of being ill
• “Paradox of Health”:
Malaise with regards to physical or psychical well being
without a clinically sound objective parameter
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Epidemiology – Descriptive Epidemiology I

What is a disease / an illness? (cont)

• Definitions of diseases are subject to agreement
• Classification system experiences a continuous change
• Naming of diseases according to
– Author names [Morbus Bechterew]
– Popular speech [Cold]
– Description or assumption of reason for disease [Hay fever]
– Cardinal symptoms [Whooping cough]
– Anatomic location [Epicondylitis laterali]
– Main diagnostic findings (pathology, anatomy) [Endangiitis
obliterans]
– Made-up words / abbreviations [HIV / AIDS / HUS]
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 Epidemiology – Descriptive Epidemiology I

ICD-10: International Classification of Disease and related

health problems / 10th revision

www.dimdi.de
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Epidemiology – Descriptive Epidemiology I

Frequency depends on the definition of a case

Fletcher & Fletcher: Clinical Epidemiology, The Essentials; 4th ed. 2005, Lippincott Williams & Wilkins
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 Epidemiology – Descriptive Epidemiology I

Measuring and documentation of clinical data

Uniform and standardized measurement

and documentation is the precondition for

– Classification of a disease
– Observation of the clinical course

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Epidemiology – Descriptive Epidemiology I

„W“ 2, 3, and 4

deal with describing the frequency

• Who = person age, sex, sociodemographics?
• Where = place regions, countries?
• When = time seasonal, secular trends?

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 Epidemiology – Descriptive Epidemiology I

Approach to describe the frequency of a disease

• Define and count the cases (persons with disease)

– Note: there is a difference between
many cases / little vs. frequent / non frequent

• Define and count the population („persons at risk“)

• Define the time frame

• Compute:
=

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Epidemiology – Descriptive Epidemiology I

What is a case [in epidemiology]?

• A person who has the disease of interest

• Defined by inclusion and exclusion criteria

• Cave:
– suspected diagnosis
– misdiagnosis, misclassifications
overestimation/underestimation of the frequency

• Important: Standard definition of diagnosis (ICD-10)

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 Epidemiology – Descriptive Epidemiology I

What is a population [in epidemiology]?

• Group of persons with well defined (common)

characteristics (inclusion/exclusion criteria)

– demographics: sex, year of birth 1990, aged 75 yrs

– disease related characteristics: persons with rubella [Röteln], HIV-
infection
– geographics: residents of Germany, 10 km around nuclear power
station
– group membership: students of Luebeck university, smoker
– time: patients of the university hospital Schleswig-Holstein in 2016

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Epidemiology – Descriptive Epidemiology I

Fixed vs. open population

Fixed population Dynamic / open population
Key element Membership is based on an Membership is based on a
event and is permanent. condition (changeable state).
Will never gain new Membership is transitory.
members.
Example Japanese atomic bomb Residents of a city, hospital
survivors patients

Fletcher & Fletcher: Clinical Epidemiology, The Essentials; 4th ed. 2005, Lippincott Williams & Wilkins
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 Epidemiology – Descriptive Epidemiology I

What is a population [in epidemiology]? (cont.)

• Population at risk:
It must be possible to move from denominator to numerator

• Sometimes this transition is not possible:

– biological:
men not at risk for miscarriage
women not at risk for prostate cancer
– disease related: immunity, patients with chronic diseases
– geographical: malaria in Germany

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Epidemiology – Descriptive Epidemiology I

Incidence vs. Prevalence

• Prevalence
– Existing cases:
What proportion of
a population acutally has
the disease?

• Incidence
– Occurence of new cases:
How quickly are people
catching the disease?

Gordis: Epidemiology, 4th ed. 2008, Saunders, Elsevier

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 Epidemiology – Descriptive Epidemiology I

Gordis: Epidemiology, 4th ed. 2008, Saunders, Elsevier 22

Epidemiology – Descriptive Epidemiology I

Incidence risk (IR)

• Anwers the question: „At what rate do new cases arise in

a defined population as time passes“
• Measures how quickly people develop the disease

• Occurrence of new cases of disease commencing during

a certain time period in a well defined population (at risk)

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 Epidemiology – Descriptive Epidemiology I

Incidence risk (IR) – example

During 2016 in example city, 750 people fell ill for the first
time with a hospital-acquired pneumonia.
Example city had a mean population of 250,000 inhabitants
in the year 2016.
Calculate the incidence risk!

IR = 750 / 250,000
= 0.003 per year
= 300 per 100,000 per year

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Epidemiology – Descriptive Epidemiology I

Cumulative risk / cumulative incidence

• Measures the proportion of people who develop the disease
during a specified period
• Risk to an individual that a given health event will occur during
a specified period without regard for the time at which that
event occurs = risk (probability) to become a case

• in longitudinal studies & studies with a fixed population

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 Epidemiology – Descriptive Epidemiology I

Cumulative risk / incidence – example

120,000 women are observed for eight years, 270 strokes

occur during this time.
What is the cumulative incidence? What is the likelihood to
experience a stroke within one year’s observation time?

Cum. Incidence = 270/120,000

= 0.00225
= 2.25 per 1,000
Likelihood = 0.00225 / 8
≈ 0.025%
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Epidemiology – Descriptive Epidemiology I

Cumulative lifetime incidence – lifetime risk

• Measures the proportion of people who develop the

disease during their lifetime (often defined as 0-74 yrs)

• Often used in oncology

– breast cancer and prostate cancer: 13% (1 out of 8)

– lung cancer in men: 7% (1 out of 14)

– lung cancer in women: 3% (1 out of 34)

• NOTE: valid for current conditions of morbidity

and earlier exposition patterns
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 Epidemiology – Descriptive Epidemiology I

Incidence (density) rate (IDR)

• Relates the number of new cases to the person-time at risk
(Person-time = total time that subjects in the population are at risk
during the observation period)

• Measures the proportion of people who develop the disease during

a specified period

• Reciprocal value = time up to the first occurrence of the disease

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Epidemiology – Descriptive Epidemiology I

Incidence (density) rate (cont.)

• Interpretation: power of disease /“speed of morbidity“
BUT: interpretation not for individuals, but for the population

• NOTE: after the disease onset the subject is no longer at risk

[until the end of the disease]

• THEREFORE: persons who become a case during the observation

period do not contribute to the person-time at risk any more

• BUT: it is possible to return to being „at risk“ after recovering

– after the end of disease the subject‘s time at risk will start again
(in case of no immunology)

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 Epidemiology – Descriptive Epidemiology I

Incidence (density) rate (cont.)

• In a fixed/static population the denominator is:

– number of persons at risk x observation period
• In a dynamic/open population the denominator is:
– individual data needed
– denominator estimation by the average population x time period

• Often given as „per 100,000 person years“

• 1,000 persons x 5 years = 5,000 persons x 1 year

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Epidemiology – Descriptive Epidemiology I

IDR example I (quite simple)

5 o

4
5 persons
15 ( 14) person-years
3 o
1 incident case
2 o 3 loss to follow up

0
t0 t1 t2 t3 t4

o > +
healthy period disease period leaves the enters the death
tn to tn+1 = years population population

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 Epidemiology – Descriptive Epidemiology I

IDR example I (quite simple)

Calculate the incidence density rate
5 o
and the time up to the
4 first occurrence of the disease.
Incidence density rate:
3 o IDR = cases / person-years
IDR = 1 / 14 = 0.07
2 o IDR = 0.07 cases per person-year

1 Waiting time property of incidence rate:

1 / IDR = 1 / (0.07 / 1 py) = 13
0 In average, 13 years elapse
t0 t1 t2 t3 t4 until a new case occurs
o > +
healthy period disease period leaves the enters the death
tn to tn+1 = years population population

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Epidemiology – Descriptive Epidemiology I

IDR example II (a little less simple)

5 +

4 o
5 persons
3 > +
11 person-years (!)
3 incident cases 2
2 deaths
1 loss to follow up 1

0
t0 t1 t2 t3 t4
o > +
healthy period disease period leaves the enters the death
tn to tn+1 = years population population

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 Epidemiology – Descriptive Epidemiology I

IDR example II (a little less simple)

Calculate the incidence density rate
and 5 +
the time up to the
first occurrence of the disease. 4 o

3 > +
Incidence density rate:
IDR = cases / person-years 2
IDR = 3 / 11 = 0.27
IDR = 0.27 cases per person-year 1

Waiting time property of incidence rate: 0

1/IDR = 1 / (0.27 / 1 py) = 3.66 t0 t1 t2 t3 t4
In average, 3 years and 8 months elapse
until a new case occurs

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Epidemiology – Descriptive Epidemiology I

Prevalence
• Anwers the question: „What proportion of a group of people
has the condition of interest?”
• Often given as cases per 1,000 persons
• Period prevalence:
Number of affected persons during a certain period in a
population during that certain period
• Point prevalence:
Number of affected persons (cases) at a specific time in a
population at that specific time

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 Epidemiology – Descriptive Epidemiology I

Relationship: Incidence, Prevalence and Duration

• When: fixed population, prevalence of disease <10%,

diseases with known duration
• Then:
prevalence ≈ incidence risk x duration
• Impact of the duration of disease:
– High prevalence (chronic diseases) (usually) low incidence
– High incidence (influenza) low prevalence

• Interpretation:
– Proportion of ill persons of the population
– Probability that a randomly chosen person has the disease of
interest at a specific point in time (day or year…)
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Epidemiology – Descriptive Epidemiology I

Summary: Frequency measures

Incidence Prevalence
New cases in a defined time Cross-sectional cut through a
period population at a defined time point

Measure of the risk Measure of the burden of disease

Duration of disease is not Duration of disease is important

important

- Incidence risk - Point prevalence

- Cumulative incidence / risk - Period prevalence
- Incidence (density) rate

Fletcher & Fletcher: Clinical Epidemiology, The Essentials; 4th ed. 2005, Lippincott Williams & Wilkins
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 Epidemiology – Descriptive Epidemiology I

Mortality risk

• Aka mortality rate, death rate

• Measures the number of deaths (in general or due to a

specific cause) in a particular population per unit of time

• Special case of incidence risk

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Epidemiology – Descriptive Epidemiology I

Case fatality rate (CFR)

• Aka case fatality risk, case fatality ratio, fatality rate

• Measure of risk
• Measures the proportion of deaths within a designated
population of "cases" over the course of the disease
• Conventionally expressed as a percentage

• CFRs are most often used for diseases with discrete,

limited time courses such as outbreaks of acute
infections

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