Chapter 3

Measures of Morbidity and Mortality Used in Epidemiology

Learning Objectives
Define and distinguish among ratios, proportions, and rates Explain the term population at risk Identify and calculate commonly used rates for morbidity, mortality, and natality State the meanings and applications of incidence rates and prevalence

Learning Objectives (contd)

Discuss limitations of crude rates and alternative measures for crude rates Apply direct and indirect methods to adjust rates List situations where direct and indirect adjustment should be used

Count
The simplest and most frequently performed quantitative measure in epidemiology. Refers to the number of cases of a disease or other health phenomenon being studied. Significant for rare diseases or symptom presentations (e.g., case of Ebola virus).

Examples of Counts
Traffic fatalities in Manhattan in a 24hour time period College dorm students who had hepatitis Foreign-born stomach cancer patients

Ratio
The value obtained by dividing one quantity by another The most general form has no specified relationship between numerator and denominator. Proportions, rates, and percentages are also ratios.

Example of a Ratio Calculation

Sex ratio (data from textbook)
Number of male cases = 950

Number of female cases

50

19:1 male to female

Definition of Proportion
A measure that states a count relative to the size of the group. A ratio in which the numerator is part of the denominator. May be expressed as a percentage.

Uses of Proportions
Can demonstrate the magnitude of a problem. Example: 10 dormitory students develop hepatitis. How important is this problem?
If only 20 students live in the dorm, 50% are ill. If 500 students live in the dorm, 2% are ill.

Example of a Proportion
Calculate the proportion of AfricanAmerican male deaths among AfricanAmerican and white boys aged 5 to 14 years.
A B Total (A + B)

Number of deaths among African-American boys

Number of deaths among white boys

Total

1,150

3,810

4,960

Proportion = A/(A + B) x 100 = (1,150/4,960) x100 = 23.2%

Rate
Definition: a ratio that consists of a numerator and a denominator and in which time forms part of the denominator. Contains the following elements:
disease frequency unit size of population time period during which an event occurs

Example of Rate Calculation

Number of deaths in a given year X 100,000 Crude death rate = Reference population (during the midpoint of the year)
Example: Number of deaths in the United States during 2003 = 2,448,288 Population of the U.S. as of July 1, 2003 = 290,810,789
Crude death rate = 2,448,288 290,810,789 = 841.9 per 100,000

Definition of Prevalence
The number of existing cases of a disease or health condition in a population at some designated time.

Analogy of prevalence and incidence: The water flowing down the waterfall symbolizes incidence and water collecting in the pool at the base symbolizes prevalence. Source: Robert Friis.

Interpretation of Prevalence
Provides an indication of the extent of a health problem.
Example 1: Prevalence of diarrhea in a childrens camp on July 13 was 33% (point prevalence). Example 2: prevalence of cancer in women during a specified time period (period prevalence)

Uses of Prevalence
Describing the burden of a health problem in a population. Estimating the frequency of an exposure. Determining allocation of health resources such as facilities and personnel.

Point Prevalence
Number of persons ill Total number in the group

Point Prevalence =

at point in time

Example:
Total number of smokers in the group = Total number in the group 6,234 = 149.0 per 1,000 41,837 or 14.9%

Period Prevalence
Period Prevalence =

Number of persons ill during a time period Average population

Example: Persons ever diagnosed with cancer = Average population 2,293 = 5.5% 41,837

Definition of Incidence
The number of new cases of a disease that occur in a group during a certain time period.

Incidence Rate (Cumulative Incidence)

Describes the rate of development of a disease in a group over a certain time period. Contains three elements:
Numerator = the number of new cases. Denominator = the population at risk. Time = the period during which the cases occur.

Applications of Incidence Data

Help in research on the etiology/causality of disease. Used to estimate
the risk of developing a disease. the effects of exposure to a hypothesized factor of interest.

Incidence Rate Calculation (IWHS Data)

Number of new cases over a time period Incidence rate = X multiplier (e.g., 100,000)

Total population at risk during the same time period

Number of new cases = 1,085 Population at risk = 37,105 Incidence rate =

1,085 37,105

= 0.02924/8 = 0.003655 x 100,000

= 365.5 cases per 100,000 women per year

Attack Rate (AR)

Alternative form of incidence rate. Used for diseases observed in a population for a short time period. Not a true rate because time dimension often uncertain. Example: Salmonella gastroenteritis outbreak Formula:
AR = Ill___ Ill + Well x 100 (during a time period)

Incidence Density
An incidence measure used when members of a population or study group are under observation for different lengths of time.

Formulas for Incidence Density

Incidence density = Number of new cases during the time period Total person-time of observation

If period of observation is measured in years, formula becomes:

Incidence density = Number of new cases during the time period Total person-years of observation

Incidence Density, Example

A B AxB Number of Subjects Length of observation (years) Person-years 30 10 300 10 9 90 7 8 56 2 7 14 1 1 1 Total 50 461 Number of health events (heart attacks) observed during the 10-year period: 5 Incidence density = (5/461) x 100 = 1.08 per 100 person-years of observation

Interrelationship Between Prevalence and Incidence

Interrelationship: P
=

ID

The prevalence (P) of a disease is proportional to the incidence rate (I) times the duration (D) of a disease.

Interrelationship Between Prevalence and Incidence (contd)

If duration of disease is short and incidence is high, prevalence becomes similar to incidence. Short duration--cases recover rapidly or are fatal. Example: common cold

Interrelationship Between Prevalence and Incidence (contd)

If duration of disease is long and incidence is low, prevalence increases greatly relative to incidence. Example: many chronic diseases

Outbreak of Meningococcal Infections in a Summer School Class of 10 Students

Students Jul 5 A B C D E F G H I J Day Su M Tu W Th F Duration of Illness Jul 14

Sa Su M

Tu W

Th F

Sa

Crude Rates, Measures of Natality

Crude birth rate Fertility rate Infant mortality rate Fetal death rate Neonatal mortality rate Postneonatal mortality rate Perinatal mortality rate Maternal mortality rate

Crude Birth Rate

Used to project population changes; it is affected by the number and age composition of women of childbearing age
Number of live births within a given period Population size at the middle of that period
Sample calculation: 4,112,052 babies were born in the U.S. during 2004, when the U.S. population was 293,655,404. The birth rate was 4,112,052/293,655,404 = 14.0 per 1,000.

Crude Birth Rate =

X 1,000 population

General Fertility Rate

Used for comparisons of fertility among age, racial, and socioeconomic groups.
# of live births within a year # of women aged 15-44 yrs. during the midpoint of the year X

General = fertility rate

1,000 women aged 15-44

Sample calculation: During 2004, there were 62,033,402 women aged 15 to 44 in the U.S. There were 4,112,052 live births. The general fertility rate was 4,112,052/62,033,402 = 66.3 per 1,000 women aged 15 to 44.

Fertility rates: United States, 1950-1992. Source: Reprinted from National Center for Health Statistics, Annual Summary of Births, Marriages, Divorces and Deaths, United States, 1992, Monthly Vital Statistics Report, Vol 41, No 13, p. 3. Hyattsville, MD: National Center for Health Statistics; 1993.

Infant Mortality Rate

Used for international comparisons; a high rate indicates unmet health needs and poor environmental conditions. Number of infant deaths among infants aged 0-365 days 1,000 live during the year X Infant mortality = births Number of live births during the year
Sample calculation: In the U.S. during 2003, there were 28,025 deaths among infants under 1 year of age and 4,089,950 live births. The infant mortality rate was (28,025/4,089,950) x 1,000 = 6.85 per 1,000 live births.

Fetal Death Rate

Used to estimate the risk of death of the fetus associated with the stages of gestation.
Fetal Death Rate (per 1,000 live births plus fetal deaths) = Number of fetal deaths after 20 weeks or more gestation

Number of live births + number of fetal deaths after 20 weeks or more gestation
Late fetal death rate (per 1,000 live births plus late fetal deaths) = Number of fetal deaths after 28 weeks or more gestation Number of live births + number of fetal deaths after 28 weeks or more gestation

X 1,000

X 1,000

Fetal Death Ratio

Provides a measure of fetal wastage (loss) relative to the number of live births. Number of fetal deaths after 20 weeks
Fetal Death Ratio = or more gestation Number of live births X 1,000 (during a year)

Neonatal Mortality Rate

Reflects events happening after birth, primarily:
congenital malformations prematurity (birth before gestation week 28) low birth weight (birth weight less than 2,500 g)

Neonatal Mortality Rate Formula

Neonatal mortality rate = Number of infant deaths under 28 days of age X 1,000 live births Number of live births (during a year)

Postneonatal Mortality Rate

Reflects environmental events, control of infectious diseases, and improvement in nutrition. Postneonatal mortality rate = Number of infant deaths from 28 days to 365 days after birth Number of live births - neonatal deaths

X 1,000 live births

Infant, neonatal, and postneonatal mortality rates: United States, 1940-2003. Source: From Hoyert DL, Heron MP, Murphy SL, Kung H. Deaths: Final Data for 2003. National Vital Statistics Reports, Vol 54, No 13, p. 12. Hyattsville, MD: National Center for Health Statistics; 2006.

Perinatal Mortality Rate

Reflects environmental events that occur during pregnancy and after birth; it combines mortality during the prenatal and postnatal periods. Perinatal mortality rate = Number of late fetal deaths after 28 weeks or more gestation plus infant deaths within 7 days of birth X 1,000 live births and fetal deaths Number of live births + number of late fetal deaths

Perinatal Mortality Ratio

Perinatal mortality ratio =

Number of late fetal deaths after 28 weeks or more gestation plus infant deaths within 7 days of birth Number of live births

X 1,000 live births

Maternal Mortality Rate

Reflects health care access and socioeconomic factors; it includes maternal deaths resulting from causes associated with pregnancy and puerperium (during and after childbirth).
Maternal mortality rate (per 100,000 live births, including multiple births) =

Number of deaths assigned to causes related to childbirth

Number of live births

X 100,000 live births (during a year)

Crude Rates
Use crude rates with caution when comparing disease frequencies between populations. Observed differences in crude rates may be the result of systematic factors (e.g., sex or age distributions) within the population rather than true variation in rates.

Specific Rates
Specific rates refer to a particular subgroup of the population defined in terms of race, age, sex, or single cause of death or illness.

Cause-Specific Rate
Cause-Specific Rate = Mortality (or frequency of a given disease) Population size at midpoint of time period X 100,000

Example:
Cause-specific mortality rate (age group 25-34) due to HIV in 2003 = 1,588/39,872,598 = 4.0 per 100,000

Proportional Mortality Ratio (PMR)

PMR (%) = Mortality due to a specific cause during a time period Mortality due to all causes during the same time period Example: PMR (%) for HIV among the 25- to 34-year-old group = 1,588/41,300 = 3.8%
Indicates relative importance of a specific cause of death; not a measure of the risk of dying of a particular cause.

X 100

The 10 Leading Causes of Death, 25-34 Years, All Races, Both Sexes, U.S., 2003 (Number in population = 39,872,598
Rank Order 1 2 3 Cause of Death Accidents (unintentional injuries) Intentional self-harm (suicide) Assault (homicide) Number 12,541 5,065 4,516 Proportional Mortality Ratio (%) 30.4 12.3 10.9 Cause-Specific Death Rate per 100,000 31.5 12.7 11.3

4
5 6 7 8 9 10

Malignant neoplasms
Diseases of the heart HIV disease Diabetes mellitus Cerebrovascular diseases Congenital malformations Influenza and pneumonia

3,741
3,250 1,588 657 583 426 373

9.1
7.9 3.8 1.6 1.4 1.0 0.9

9.4
8.2 4.0 1.6 1.5 1.1 0.9

Mortality for all causes = 41,300

Age-Specific Rate (Ri)

The number of cases per age group of population (during a specified time period). Example: Ri = Number of deaths among those aged 5-14 years X 100,000 Number of persons who are 5-14 years (during time period)

Sample calculation: In the U.S. during 2003, there were 1,651 deaths due to malignant neoplasms among the age group 5 to 14 years, and there were 40,968,637 persons in the same age group. The age-specific malignant neoplasm death rate in this age group is (1,651/40,968,637) = 4.0 per 100,000.

Method for Calculation of Age-Specific Death Rates

Age Group (Years) Under 1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Not stated Totals Number of Deaths (Di) In 2003 28,025 4,965 6,954 33,568 41,300 89,461 176,781 262,519 413,497 703,024 687,852 342 2,448,288 Number in Population (Pi) as of July 1, 2003 4,003,606 15,765,673 40,968,637 41,206,163 39,872,598 44,370,594 40,804,599 27,899,736 18,337,044 12,868,672 4,713,467 NA 290,810,789 Age-Specific Rate (Ri) per 100,000 700.0 31.5 17.0 81.5 103.6 201.6 433.2 940.9 2,255.0 5,463.1 14,593.3 NA 841.9

Adjusted Rates
Summary measures of the rate of morbidity and mortality in a population in which statistical procedures have been applied to remove the effect of differences in composition of various populations.

Direct Method
Direct method may be used if age-specific death rates in a population to be standardized are known and a suitable standard population is available.

New Standard Population

Year 2000 population
Replaces the standard based on 1940 population. Results in age-adjusted death rates that are much larger. Affects trends in age-adjusted rates for certain causes of death. Narrows race differentials in age-adjusted death rates.

Reduces the three different standards into one acceptable standard.

Direct Method for Adjustment of Rates

Age Group (Years) Under 1 1-4 2003 Age-Specific Death Rate per 100,000 700.0 31.5 Number in Standard Population, 2000 3,794,901 15,191,619 Expected Number of Deaths 26,564.08 4,784.22

5-14 15-24
25-34 35-44 45-54 55-64 65-74 75-84 85+ Totals

17.0 81.5
103.6 201.6 433.2 940.9 2,255.0 5,463.1 14,593.3

39,976,619 38,076,743
37,233,437 44,659,185 37,030,152 23,961,506 18,135,514 12,314,793 4,259,173 274,633,642

6,785.62 31,018.66
38,566.36 90,042.86 160,428.66 225,462.73 408,952.54 672,765.23 621,555.36 2,286,926.31

Age-adjusted rate per 100,000 = 832.7 (Refer to text.)

Weighted Method for Direct Rate Adjustment

Age Group (Years) Number in Standard Population, 2000 (Psi) Standard Weight (Wsi) for 2000 Age-Specific Death Rate (Ri), 2003 Wsi Ri

Under 1
1-4 5-14 15-24

3,794,901
15,191,619 39,976,619 38,076,743

0.013818
0.055316 0.145563 0.138646

700.0
31.5 17.0 81.5

9.6726
1.7420 2.4708 11.2946

25-34
35-44 45-54 55-64 65-74 75-84 85+ Totals

37,233,437
44,659,185 37,030,152 23,961,506 18,135,514 12,314,793 4,259,173 274,633,642

0.135575
0.162164 0.134835 0.087249 0.066035 0.044841 0.015509 1.0

103.6
201.6 433.2 940.9 2,255.0 5,463.1 14,593.3 N/A

14.0428
13.7865 15.4155 18.0958 148.9084 244.9682 266.3216 832.7

Indirect Method
Indirect method may be used if agespecific death rates of the population for standardization are unknown or unstable, for example, because the rates to be standardized are based on a small population. The standardized mortality ratio (SMR) can be used to evaluate the results of the indirect method.

Standardized Mortality Ratio (SMR)

Observed deaths SMR = Expected deaths

x 100

Sample calculation: The number of observed deaths due to heart disease is 600 in a certain county during year 2003. The expected number of deaths is 1,000. The SMR = (600/1,000 x 100) = 60% (0.6).

Interpretation of SMR
If the observed and expected numbers are the same, the SMR would be 1.0, indicating that observed mortality is not unusual. An SMR of 2.0 means that the death rate in the study population is two times greater than expected.

Illustration of Indirect Age Adjustment: Mortality Rate Calculation for a Fictitious Population of 230,109 Persons
Age (Years) Number in Population of Interest
7,989 37,030 60,838 68,687 55,565 230,109

Death Rates (per 100,000) in Standard Population

81.5 103.6 201.6 433.2 940.9

Expected Number of Deaths in Population of Interest

6.5 38.4 122.6 297.6 522.8

15-24 25-34 35-44 45-54 55-64 Totals

Total expected number of deaths = 987.9 Observed number of deaths in this population = 502

Indirect Age Adjustment (contd)

From previous table, SMR is (502/987.9) X 100 = 50.8%.