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ADDITIONAL NOTES ON
EPIDEMIOLOGY
Measures of disease
occurrence
 What are measures of disease
occurrence?

These are
measurements of the
frequency/magnitude
/amount of disease in
populations
 How do we measure diseases?
• Four quantitative
descriptors
– Numbers
– Ratios
– Proportions
– Rates
 Ratio
• A ratio is the relative magnitude
of two quantities or a
comparison of any two values.

• It is calculated by dividing one

interval- or ratio-scale variable
by the other.

• The numerator and

denominator need not be
related. Therefore, one could
compare apples with oranges or
apples with number of physician
visits.
 Proportion
• A proportion is the comparison of
a part to the whole.

• It is a type of ratio in which the

numerator is included in the
denominator.

• You might use a proportion to

describe what fraction of clinic
patients tested positive for HIV, or
what percentage of the population
is younger than 25 years of age. A
proportion may be expressed as a
decimal, a fraction, or a
 Rate
• In epidemiology, a rate is a measure
of the frequency with which an
event occurs in a defined population
over a specified period of time.

• Because rates put disease frequency

in the perspective of the size of the
population, rates are particularly
useful for comparing disease
frequency in different locations, at
different times, or among different
groups of persons with potentially
different sized populations; that is, a
rate is a measure of risk.
 Numbers
• Numbers: Use of
actual number of
events
– e.g 100 cases of TB in
community A
 When we call . .
• When we call a measure a
ratio, we mean a
nonproportional ratio

• When we call a measure a

proportion, we mean a
proportional ratio that doesn’t
measure an event overtime

• When we call a rate, we

mean a proportional ratio that
does measure an event in a
population overtime
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 Types of rates
• Crude rates:
– Apply to the total population
in a given area

• Specific rates:
– Apply to specific subgroups
in the population (age, sex
etc) or specific diseases

• Standardized rates:
– used to permit comparisons of
rates in population which
differ in structure (e.g age
structure)
 Morbidity
• defined as any departure,
subjective or objective, from a state
of physiological or psychological
well-being.

• In practice, morbidity
encompasses disease, injury, and
disability.

• The term refers to the number of

persons who are ill, it can also be
used to describe the periods of
illness that these persons
experienced, or the duration of
these illnesses
 Morbidity rates
• Morbidity rates are rates that
are used to quantify the
magnitude/frequency of
diseases

• Two common morbidity rates

– Incidence rates
• (Cumulative incidence,
incidence density)

– Prevalence
• (Period prevalence, point
prevalence)
 Mortality rates
• These rates measures
magnitude of deaths in a
community

• Some are crude like the crude

death rate

• Others are cause-specific

mortality rate

• Some others are adjusted like

standardized mortality ration
 Common Mortality rates
• Crude death rate
• Age-specific mortality
rate
• Sex-specific mortality
rate
• Cause-specific mortality
rate
• Proportionate mortality
ratio
• Case fatality rate
• Fetal death rate
 Common Mortality rates
• Perinatal mortality rate
• Neonatal mortality rate
• Infant mortality rate
• Child mortality rate
• Under-five mortality
rate
• Maternal mortality
ratio
 Crude mortality rate
• An estimate of the rate at which members of a
population die during a specified period.

• The numerator is the number of people dying during

the period; the denominator is the size of the
population, usually at the middle of the period (mid-
year population).

Number of deaths during a specified period

Number of persons at risk of dying during the x 10n
period.
 Crude mortality rate
• Counts all deaths
– All causes
– All ages and both sexes

• Denominator includes entire population

– All ages and both sexes
 SPECIFIC RATES
• In contrast to crude rates, a specific
rate refers to a particular segment of
the population.

• It focuses attention on a more

homogeneous group within the total
population and

• Rates may also be made specific for

more than one characteristic of the
population, such as age-, sex-, and race-
specific death rates.

• Is expressed on the basis of any

characteristic of the population such as
– age, sex, marital status, race, etc.
 STANDARDIZED MORTALITY RATE
(SMR)
• Standardization is used
when comparing mortality
in two populations that
have different demographic
structures.

• Standardization can be
either direct (leading to an
Age-Standardized Mortality
Rate [ASMR]) or indirect
(producing a Standardized
Mortality Ratio [SMR]).
 STANDARDIZED MORTALITY RATE
(SMR)
• It removes the effect of
differences in age (or other
confounding variables that
affect mortality rate) between
the populations.

– For example, Victoria, B.C. has

more elderly people than
Whitehorse, Yukon, so a crude
comparison of overall mortality
rates per thousand would not be
helpful because we would expect
higher death rates in Victoria
simply because of its older
population.
 Age-specific mortality rate
• Counts only deaths in
specific age group
– Usually calculated for
children less than 5
years of age
• Denominator
includes only persons
in that age group
 Infant mortality rate
• The infant mortality rate is the total number of
deaths in a given year of children less than one
year old, divided by the total number of live
births in the same year, multiplied by 1,000.
• It is an approximation of the number of deaths
per 1,000 children born alive who die within
one year of birth.

• Infant mortality rate = Deaths among children less than 1 year of age x 1000
Number of live births in the same year
 Infant mortality rate
• The IMR is often quoted
as a useful indicator of
the level of health
development in a
community.

• Counts deaths in
children less than 12
months of age, divides
by number of live births
in same time period
 PERINATAL MORTALITY RATE
(PMR)
• In most industrially developed nations, this is
defined as

Fetal deaths (>28 weeks of gestation) +

deaths occurring within 1 week postnatally
x 1000
Fetal deaths (>28 weeks of gestation) + live
births
 NEONATAL MORTALITY RATE
(NMR)

• Deaths in infants under 28 days of age in a year x 1000

Live births in same period.
 Maternal mortality rate
• The number of maternal
deaths related to
childbearing divided by the
number of live births (or by
the number of live births +
fetal deaths) in that year.

• Counts deaths in women due

to pregnancy or child birth,
divides by number of live
births in same time period
 Under-5 mortality rate
• Counts deaths in the
first 5 years of life,
divides by number of
live births in the
hypothetical cohort
of newborns.
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 Epidemic Disease Occurrence
• Level of disease
– The amount of a particular
disease that is usually
present in a community is
referred to as the baseline or
endemic level of the disease.
• Epidemics
– occur when an agent and
susceptible hosts are
present in adequate
numbers, and the agent can
be effectively conveyed from
a source to the susceptible
hosts.
 Epidemic Disease Occurrence
• More specifically, an epidemic may
result from:
1) A recent increase in amount or
virulence of the agent,
2) The recent introduction of the
agent into a setting where it has
not been before,
3) An enhanced mode of
transmission so that more
susceptible persons are
exposed,
4) A change in the susceptibility of
the host response to the agent,
and/or
5) Factors that increase host
exposure or involve introduction
 Sporadic
• refers to a disease
that occurs
infrequently and
irregularly

• Ex.
(Single case of
histoplasmosis was
diagnosed in a community.)
 Endemic
• refers to the constant
presence and/or usual
prevalence of a disease or
infectious agent in a
population within a
geographic area

• Ex.
(About 60 cases of gonorrhea are
usually reported in this region per
week, slightly less than the
national average.)
 Hyperendemic
• refers to persistent,
high levels of disease
occurrence.

• Ex.
(Average annual incidence was
364 cases of pulmonary
tuberculosis per 100,000
population in one area, compared
with national average of 134
cases per 100,000 population)
 Epidemic
• refers to an increase, often
sudden, in the number of
cases of a disease above what
is normally expected in that
population in that area
• Outbreak carries the same
definition of epidemic, but is
often used for a more limited
geographic area

• Ex.
(22 cases of legionellosis occurred within
3 weeks among residents of a particular
neighborhood (usually 0 or 1 per year)
 Pandemic
• refers to an epidemic
that has spread over
several countries or
continents, usually
affecting a large
number of people.

• Ex.
– (Over 20 million people worldwide
died from influenza in 1918–1919)
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