Frequency

Sadik A. Khuder, Ph.D.,

College of Medicine
University of Toledo
 Types of Calculations
Type of calculation Characteristics
Ratio Division of two unrelated numbers
Proportion Division of two related numbers;
numerator is a subset of denominator
Rate Division of two numbers; time is
always in denominator

The “sex ratio” is a ratio of two unrelated numbers: the

number of males divided by the number of females, usually
expressed as the number of males per 100 females.
In 2000 U.S. Census data, the sex ratio among U.S.
residents aged 65 years and older was 73.7 males per 100
females.
 Types of Calculations
Type of calculation Characteristics
Ratio Division of two unrelated numbers
Proportion Division of two related numbers;
numerator is a subset of denominator
Rate Division of two numbers; time is
always in denominator

The proportions, also known as fractions, are often

expressed as percentages and range from 0 to 1 or 0%
to 100%.
In 2000 U.S. Census data, the proportion of black U.S.
residents was 0.125 or 12.5%. The remaining
proportion included whites (0.762 or 76.2%) and other
or multiple races (0.112 or 11.2%).
 Types of Calculations
Type of calculation Characteristics
Ratio Division of two unrelated numbers
Proportion Division of two related numbers;
numerator is a subset of denominator
Rate Division of two numbers; time is
always in denominator
The rate is also one number divided by another, but
time is an integral part of the denominator.
The measures of disease occurrence for two counties
A and B are rates (for example: 200 cases/100,000
population/one year and 500 cases/100,000
population/one year, respectively).
 Prevalence

 A prevalence is the fraction (proportion) of a group of

People possessing a clinical condition or outcome at a
given point In time.

Point prevalence: measured at the time of survey for each

Person, although not necessarily the same point in time for all
the people in the defined population.

Period prevalence: refers to cases that were present at

any time during a specific period of time.
 Examples

 Point prevalence
• Do you have health condition now?
 Period prevalence
• Have you had health condition during past six
months?
 Lifetime prevalence
• Have you ever had health condition?
 Period prevalence rate

 Proportion of individuals in a specified population

at risk who have the disease of interest over a
specified period of time.
 For example: annual prevalence rate, lifetime
prevalence rate.
 (when the type of prevalence rate is not specified
it is usually point prevalence, or its closest
practical approximation)
 Prevalence

 Numerator
– all those with the attribute at a particular time
 Denominator
– the population at risk of having the attribute
during that same time period

Number of prevailing cases

P
Number in the population
 Importance of Prevalence Data
Burden of illness in population
 Treatmentneeds
 Burden on social services
 Burden on individual well-being
Burden of health condition?
 Need to assess severity as well as frequency
• High frequency, low individual burden
• Low frequency, high individual burden
• Cost of treating, diagnosis, lost productivity, long-term care
etc. also important
 Importance of Prevalence Data
 Comparing prevalence rates (which have been
standardized on the same unit of population) allows
you to see if a certain disease is significantly more
prevalent in some areas than in others.
 Also, prevalence rates can be applied to future
population projections.
 Such estimates can be useful for long-range
health care planning and for comparing prevalence
among regions.
 Importance of Prevalence Data
 The primary importance of prevalence estimates is
to gain an understanding of the proportion of people
in a given population at a given point in time who
remain alive after having received a diagnosis of a
disease.
 Such statistics should be useful to agencies
charged with planning for the provision of health and
services such as continuing therapy, including the
treatment of subsequent disabilities, continuing
medical consultations, screening for recurrences and
for long-term counselling and support.
 Incidence
 An incidence is the fraction or proportion of a
group of people initially free of the condition that
develops it over a given period of time.

 Incidence refers then to new cases of disease

occurring in a population initially free of the
disease or
 new outcomes, such as disability or death
occurring in patients with a specific disease.
 Incidence

Incidence = Number of new cases/events in a

population, over a period of time.
Example:
 The incidence of AIDS in a specific population
was 200 in 2008
 The incidence here refer to 200 new cases of
AIDS that were diagnosed in 2008.
 Incidence rate

 Incidence density is also known as incidence

rate, person-time incidence rate, instantaneous
incidence rate, hazard rate and force of morbidity
or mortality

 Cumulative incidence is usually simply referred to

as incidence rate (or rarely, cumulative
proportion)
 Incidence

Cumulative Incidence: the probability (risk) of

an individual developing the disease (outcome)
during a specific period of time.

Number new cases of disease over a study period

I
Population at risk at the start of the study
 Cumulative Incidence

Example 1:
 The daily incidence of chickenpox in first grade
children at a primary school during the 1998
epidemic was 10 new cases per 100 children.
 If there were 200 children in the first grade, how
many new cases would there be each day?
 Answer 20
 Cumulative Incidence

Example 2
 600 women had in vitro fertilization in a specific
clinic during 2008
 140 women were pregnant within one month of
follow-up after the first embryo transfer procedure.
 The cumulative incidence = 140/600 = 23.3 cases
per hundred women on the program
 Example 3
Twenty patients with comparable degree of knee pain from osteoarthritis, were
compared with respect to pain relief after receiving a standard pain medication
(Old drug) or a new pain medication (New drug).
Patients were randomly assigned to one drug or the other (10 in each group).
After receiving the medication, the investigators checked at hourly intervals to
see if the subjects had had relief of pain.
For each subject, the time at which pain relief occurred was recorded.
New Drug Old Drug

Hours to Pain Relief Hours to Pain Relief

The "X"s indicate when subjects reported pain relief. The "O"s at the end indicate subjects who did not report relief of pain.

Six subjects in each group experienced relief of pain, so the cumulative incidence of pain
relief was 6/10 = 60% in each group.
For cumulative incidence, one determines the proportion of subjects who experienced the
outcome of interest during a block of time, without taking into account when subjects
developed the outcome.
Visually, however, it is clear that if we consider when subjects experienced relief, the rate
was greater in the subjects receiving the new drug.
 Incidence density
The probability (risk) of an individual
developing the disease (outcome) during a
specific period of time, using total person-time
as the denominator. One subject followed one
year contributes one person-year (PY).

Number cases of disease during a

given time period
I density 
Total person - time
Examples of person-time units according to the
frequency of events under investigation.
Population Event studied Person-time unit
Typically used
General Incident breast cancer Person-years
General Incident myocardial infarction Person-years
Malnourished children Incident diarrhea Person-months
Lung cancer cases Death Person-months
Influenza epidemic Incident influenza Person-weeks
Children with acute Recovery Person-days
diarrhea
Subjects in clinical trial Pain relief Person-hours
 Incidence Density-Example 1
New Drug Old Drug

Hours to Pain Relief Hours to Pain Relief

The "X"s indicate when subjects reported pain relief. The "O"s at the end indicate subjects who did not report relief of pain.

In this example, all subjects were observed for a maximum of 10 hours,

and some did not achieve pain relief, while others got relief after
varying periods of time.
In the new drug group, the times were 4x1 + 2 + 3+ 4x10= 49 hours for
the group (person-hours). So the incidence rate of relief was 6/49
person-hours or on average 12.2 per 100 person-hours of observation.
In the old drug group, the times were 4x7 + 8 + 9 + 4x10= 85 hours for
the group (person-hours). So the incidence rate of relief was 6/85
person-hours or on average 7.0 per 100 person-hours of observation.
So, the rate of pain relief was greater in the group receiving the new
drug.
 Incidence Density-Example 2

 In investigating the incidence of duodenal ulcer following

the use of a specific drug in 14 subjects. 4 subjects
started the study in Jan 1990 and all finished the study in
Dec 1999. Ten subjects joined the study in Dec1995 and
finished the study in November 1996. During the period of
observation: 5 people developed duodenal ulcer while
taking the drug.
 Total length of time that persons were in the population is
at risk= 4 X 10 + 10 x 1 = 50 person-years
 New cases = 5
 The incidence rate of duodenal ulcers after taking the drug
= 5 / 50 = 10 cases per 100 person-years
 Incidence Density-Example 3
 Consider a study consisting of 12 people depicted below. None of the subjects had
the disease of interest at the beginning of the study. Some subjects were enrolled
in 1980 and others in were enrolled in 1981 During the 15 year observation period,
subjects 2, 5, and 11 developed disease after 10, 4, and 7 years of observation
respectively. In addition, six subjects became lost to follow up at various times,
and only two subjects (#3 and #4) remained disease free all the way to 1995 when
the study ended.
 Incidence Density-Example 3
Person-time
At risk
8
x 10

15

15

x 4

12

11

9
x 7

Entered the study x When disease occurred Left the study

The sum of person-time at risk = 8+10+15+15+4+12+7+11+3+9+7+ 3 = 104

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑜𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛 𝑝𝑒𝑟𝑖𝑜𝑑

Incidence Rate =
𝑆𝑢𝑚 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛−𝑡𝑖𝑚𝑒 𝑎𝑡 𝑟𝑖𝑠𝑘

3
= 104 = 2.9 per 100 person-years
person−years
 Cumulative Incidence vs Incidence Density
Cumulative Incidence
Strengths Easily calculated and
understood since it measures
risk
Limitations Does not take into account
losses to follow up
or when disease occurs
Appropriate Fixed populations with short
Use follow-up, or no losses to
follow-up
Incidence Density
Takes into account
losses to follow up
and when disease
occurs
Need individual follow-
up, which is costly and
time-consuming
Interpretation is not
intuitive
Dynamic populations
Fixed populations with
long follow-up times,
or substantial loss to
follow up
 Appropriate Frequency Measure to Use
Example Measure
80% of people will experience back pain sometime Cumulative incidence
in their lifetime.
About 2% of the U.S. workforce is compensated for Incidence density
back injuries each year.
30% of adults have low back pain at any given time. Point prevalence

Have you ever had health condition? Lifetime prevalence

The risk of developing influenza among seniors Incidence density
vaccinated against the disease.

A pediatrician needs to describe an overweight Cumulative incidence

child’s likelihood of developing type 2 diabetes in
the context of the next 10 years.
Percent of adults who experienced serious Period prevalence
psychological distress during the past 30 days.
Have you ever smoked cigarette? Lifetime prevalence
 Attack Rate
 Attack rate is a type of cumulative incidence applied to a
narrowly defined population observed for a limited period of
time, such as during an epidemic.

Number of new cases of illness during a specified time period

Attack Rate =
Total population at risk during that specified period
 Attack Rate - Example
An epidemiologist was called in to investigate
more than 20 reports of people being ill with
gastroenteritis after eating at a large restaurant in
the city during the first week of 2008.
 An investigation was conducted interviewing all
patrons who ate at the restaurant during that week
 She found 2000 patrons ate at the restaurant that
week and 400 became sick.
 What was the attack rate?
 Attack rate = 400/2000 = 20 ill per 100 patrons
 Case fatality rate
Number of individuals dying during a specified period of
time after disease onset or diagnosis
Case fatality rate=
Total number of individuals with the disease during that
specified period of time
Example
 Assume a population of 100,000 people of whom 20 are
sick with disease ‘X’, and in 1999, 18 die from the
disease.
 The mortality rate = 18/100,000 = 0.018 per 1,000 pop in
1999
 The case-fatality rate=18/20 = 90% or 90 per 100 people
with ‘X’
 Measuring Prevalence and Incidence

Characteristic Incidence Prevalence

Numerator New cases occurring during All cases counted on a

A period of time among a group single survey or
initially free of disease examination of a group
Denominator All susceptible people present All people examined,
at the beginning of the period including cases and
noncases
Time Duration of the period Single point

How measured Cohort study Prevalence (cross-

sectional study)
 Uses of Incidence and Prevalence
 Incidence is generally used for acutely acquired
disease, prevalence for states, conditions or
attributes.
 Incidence is more important when thinking of
etiology of the disorder, prevalence when
thinking of societal burden of the disorder
including the costs and resources consumed as
a result of the disorder.
 Incidence always requires a duration,
prevalence may or may not.
 Uses of Incidence and Prevalence
 Predicting the future: The important distinction to
make between incidence and prevalence is the
consideration of time
 prevalence represents the current or past state
of a population
 incidence allows for the prediction of future
events within a population.
 Assigning a probability that a patient has the
condition: A useful way to think about cumulative
incidence is that it is the probability of developing
disease over a stated period of time.
 Making comparisons: Both incidence and
prevalence are useful for frequency comparisons
 Prevalence data
 Can determine the probability that person has
disease
 Cannot determine how likely someone will
develop disease
 What is risk of developing disease?
 What is my risk of disease compared with
your risk of disease?
– Need to assess incidence (risk)
 Prevalence data
Since prevalence can be influenced by many
factors unrelated to the cause of the disease,
prevalence studies do not usually provide strong
evidence of causality.
Measures of prevalence are helpful in assessing
the need for preventive action, healthcare and
the planning of health services.
Prevalence is a useful measure of the
occurrence of conditions for which the onset of
disease may be gradual, such as maturity-onset
diabetes or rheumatoid arthritis.
 Incidence Studies
 Need longitudinal design
 Define population at risk
• No disease, but able to get disease
Track new cases in a specified time period
• Called incident cases
 Cohort study
 Incidence cohort
• Follow subjects until they develop the outcome
of interest
 Interpreting Measures of Clinical Frequency
What is the population? Defining the denominator

1. The population at risk means susceptible to the disease

or outcome counted in the numerator

2. Include the population relevant to the question being

asked

3. In studies of clinical questions, the relevant populations

consist of patients suffering from certain diseases or
exhibiting certain clinical findings and who are found in
clinical setting that are similar to those in which the
information will be used.
 Sampling

Probability Sample

Biased Sample
 Bias in Prevalence Studies
Uncertainty about temporal sequences

Possible causes Incidence Study Disease or Outcome

Measurement is
Population free development of
of disease but new cases of
exposed/ not disease over time
exposed to
Possible causes

Prevalence Study

Measurement is Population of
past or present existing causes
exposure to & non cases
possible causes
 Bias in Prevalence Studies
Bias studying “old” cases

Defined Population Disease/Outcome

Present?

Representative
Population Sample
at risk
No
..……………………….......
 Relation between incidence and prevalence
 The relationship between incidence and
prevalence is dynamic
 the addition of new cases (incidence) is increasing
the prevalence,
 while the deaths/cures are decreasing the
prevalence in the given population
 In a steady-state equation where the rates are
not changing and in-migration equals out-migration,
the equation is

Prevalence = Incidence X Duration of Disease

 Relation between incidence and prevalence
 Some advances in medicine will increase the prevalence
of disease: Examples, diabetes, asthma, leukemia.
 Screening programs – artificially increase the survival
rates and prevalence.

 In this example, incidence rates are increasing and death

rates are constant, therefore prevalence rates are expected
to increase.
Incidence

Prevalence

Population at risk

Relationship between incidence and prevalence.

 Factors influencing prevalence
Increased by: Decreased by:
Longer duration of the disease
Shorter duration of the disease
Prolongation of life of High case-fatality
patients without cure rate from disease
Increase in new cases Decrease in new cases
(increase in incidence) (decrease in incidence)
In-migration of cases In-migration of healthy people
Out-migration of healthy people
Out-migration of cases
In-migration of susceptible people
Improved diagnostic facilities Improved cure rate of cases
(better reporting)

Adapted from Bonita et al, Basic epidemiology, WHO

 Epidemic Curve
 Is a graphical depiction of the number of cases
of illness by the date of illness onset
 An epidemic curve can provide information on
the following characteristics of an outbreak:
Pattern of spread
Magnitude
Outliers
Time trend
Exposure and/or disease incubation period
 Outbreak Pattern of Spread
 The overall shape of the epidemic curve can
reveal the type of outbreak
 Common source
 Point source
 Propagated
 Common Source
 People are exposed continuously or intermittently to a
harmful source
 Period of exposure may be brief or long
 Intermittent exposure often results in a curve with irregular
peaks that reflect the timing and the extent of exposure

Outbreak with Intermittent Exposure

 Common Source
 Continuous exposure will often cause cases to rise
gradually (and possibly to plateau, rather than to peak)

Outbreak with Continuous Exposure

 Point Source
 Typically shows a sharp upward slope and a gradual
downward slope
 Is a common source outbreak in which the period of
exposure is brief, and all cases occur within one
incubation period

Outbreak with point source Exposure

 Propagated
 Is spread from person to person
 Can last longer than common source outbreaks
 May have multiple waves
 The classic curve for a propagated outbreak has
progressively taller peaks, an incubation period apart

Outbreak with propagated Exposure

 Incubation Period

 The time between the exposure and the peak

of the epidemic curve represents the median
incubation period
 In common source outbreaks with known
incubation periods, epidemic curves can help
determine the average period of exposure
 Most Suited Studies for Frequency of a Disease
Disease Prevalence Most Suited Studies
Acute disease Large variability: High Longitudinal studies
(infectious disease) during epidemics, (mandatory reports to
otherwise close to zero health authorities)
Diseases with high Low prevalence Longitudinal studies
fatality rate (cancer) (cancer registries)
Chronic-degenerative Long duration, hence Cross-sectional
diseases (CHD, CVD, high prevalence studies
COPD, diabetes
mellitus, osteoarthritis)