Morbidity

Mortality

Basic Measurements of
Epidemiology
 Measurement of Mortality

 Easy to obtain and in most of the countries

very accurate
 International Death Certificate
 Death certificate used in India
 Measurements in Epidemiology
a. Measurement of mortality

b. Measurement of morbidity

c. Measurement of disability

d. Measurement of natality

e. Measurement of the presence, absence, or

distribution of the characteristic or attributes
of the disease
f. Measurements of medical needs, health care facilities,
utilization of health services and other health- related
events

g. Measurements of the presence, absence or distribution

of
the environmental and other factors suspected of causing
the disease

h. Measurements of demographic variables

Requirements of measurements are:

• Reliability * Validity
• Accuracy * Sensitivity and
• Specificity
 Uses of Mortality Data

 Explaining trends and priorities for health

actions and allocation of resources

 Designing intervention programmes

 Assessingand monitoring of public health

problems and programmes

 Important clues for epidemiological research

 Limitations of Mortality Data
 Incomplete reporting of deaths: Developing
countries

 Lack of accuracy: age and cause of death

 Lack of uniformity: no uniform method

 Choosing a single cause of death: underlying cause,

risk factor

 Changing

 Diseases with low fatality: mental diseases, arthritis

Tools of Measurement

 Rates

 Ratios

 Proportion
Tools of measurements
1. Rates: rate measures the occurrence of some particular
event
number of deaths in one year
Death rate= ------------------------------------x1000
mid- year population

Elements of rates:
numerator, denominator, time specification and multiplier

Categories of rates:
• Crude rates/unstandardized-actual observed rates
• Specific rates-actual observed rates due to specific
causes, groups, or time
• Standardized rates
2. Ratio:

Ratio expresses a relation in size between two random

quantities.
x
x:y or ---- eg. Sex ratio
y

Numerator is not a component of denominator

3. Proportion:

Proportion is a ratio which indicates the relation in

magnitude of a part of the whole

No of children with scabies at a certain time

Eg. ----------------------------------------------------- x 100
Total no of children in the village at the same time
 Concept of numerator and denominator

Numerator:
• Number of times an event has occurred, during
specified time
• Sickness, birth, death

Denominator:
• Related to population
• Related to total events
Related to population:
Mid-year population:
• Population size changes daily
• MYP – commonly –denominator
• Mid-point refers to the population estimated as on
the first of july of an year
Population at risk
Person-time
Person-distance
Subgroups of the population-age, sex, occupation,
social class
Related to total events:

Ex: the number of accidents per 1000 vehicles

Mortality rates and ratios

1.Crude death rate

The no of deaths (from all causes) per 1000 estimated

mid-year population in one year, in a given place

No of death during the year

Crude death rate= ------------------------------------x1,000
mid year population

CDR lack comparability for communities with

populations that differ by age, sex, race, etc.
2. Specific death rates:

specific death rates may be

a. Cause or disease specific e.g; TB, Cancer
b. Related to specific groups e.g; age specific, sex-specific

No of deaths from TB during a calendar year

Specific death rate due to TB= ------------------------------------------x1,000
mid-year population

No of deaths in a particular population

Age specific death rate=------------------------------------------------x 1,000
Mid year population of that age group
 No of deaths of person aged 15-20 during a
calendar year
Specific death rate in age group= ------------------------------------x 1,000
15-20 years Mid year population of person aged 15-20

Male deaths
Sex specific death rate=---------------------x 1, 000
Mid year population of males

No of deaths among males during a calendar year

Specific death rate for males= -----------------------------------------x1,000
mid-year population of males
 Female deaths at specific aged 15-20 years
Age-Sex specific death rate=-----------------------------------------x 1,000
Female population aged 15-20 years

Deaths in January x 12
Death rate for January= -----------------------x 1,000
Mid- year population

Deaths in the week x 52

Weekly death rate = ---------------------------- x 1,000
Mid- year population
3. Case fatality rate (Ratio)-killing power of a disease
Total number of deaths due to a particular disease
= ---------------------------------------------------------x100
Total number of cases due to the same disease

4. Proportional mortality rate (Ratio) (100/1000)

a. Proportional mortality from a specific disease

No of deaths from the specific disease in a year
= ---------------------------------------------------------x100
Total deaths from all causes in that year

b. Under -5 proportionate mortality rate

No of deaths under 5 years of age in the given year
= --------------------------------------------------------------x100
Total no of deaths during the same period
c. Proportional mortality rate for aged 50 years and above
No of deaths of persons aged 50 years and above
= -------------------------------------------------------------x 100
Total deaths of all age groups in that year

5. Survival rate:
Total no patients alive after 5 years
= ------------------------------------------x100
Total no of patients diagnosed or treated

6. Adjusted or standardized rates:

 6. Adjusted or standardized rates:
• To compare the death rates of two populations
with different composition
• Age adjustment or age standardization – single
standardized or adjusted rate
• Standard Population is defined as one for which
the numbers each sex and age are known
• Not only for age, but also for sex, race.....

• Direct standardization
• Indirect standardization
 Direct standardization
1. Apply to the standard population the age
specific rates of the population whose crude
death rate to be adjusted or standardized

2. each age group a expected number of deaths

in the standard population is obtained; this is
added together for all the age groups to give
the total expected deaths

3. Divide the expected total number of deaths by

the total of the standard population which
yields the standardized or age adjusted rate
 Example
Calculating age specific death rates for City X
Age Mid year population Deaths in the year Age specific death
per 1000 rates
0 4,000 60 15.0

1-4 4,500 20 4.4

5-14 4,000 12 3.0
15-19 5,000 15 3.0
20-24 4,000 16 4.0
25-34 8,000 25 3.1
35-44 9,000 48 5.3
45-54 8,000 100 12.5
55-64 7,000 150 21.4
53,500 446

Crude death rate per 1000 = 8.3

 Example
Calculating age standardized death rates for City X
Age Standard population Age specific death Expected deaths
rates
0 2,400 15.0 36
1-4 9,600 4.4 42.24

5-14 19,000 3.0 57

15-19 9,000 3.0 27

20-24 8,000 4.0 32

25-34 14,000 3.1 43.4

35-44 12,000 5.3 63.6

45-54 11,000 12.5 137.5

55-64 8,000 21.4 171.2

93,000 609.94

Standardized death rate per 1000= (609.94/ 93,000)* 1000 = 6.56

Indirect age standardization

• Standardized mortality ratio

Observed deaths
--------------------------X 100
Expected deaths
Indirect age standardization

 It gives a measure of the likely excess

risk of mortality due to the occupation

Advantage over Direct method:

 it permits adjustment for age and other
factors where age specific rates are not
available or are unstable because of small
numbers
 Measurement of morbidity
Morbidity is defined as “any departure, subjective, or
objective, from a state of physiological well-being”
Morbidity=sickness, illness, disability

Morbidity could be measured in terms of 3 units

a. persons who were ill

b. the illnesses (spells of illness) that these persons

experienced and

c. the duration of these illnesses

Measurement of morbidity

Morbidity rates:
1. Disease frequency=incidence and prevalence

2. Duration of illness=average duration/case or the

disability rate

3. Severity of illness=case fatality rate

Population at risk
Portion of a population that is susceptible to a
disease

Can be defined on the basis of demographic or

environmental factors

Population at risk of developing carcinoma of

the cervix:
• Female population
• Age > 30 and < 70 years
Value of morbidity data

a. They describe the extent and nature of the

disease load in the community

b. assist in the establishment of priorities

c. They provide more comprehensive and more

accurate and clinically relevant information

d. essential for basic research

Value of morbidity data

a. They serve as starting point for etiological

studies

b. Play a crucial role in disease prevention

c. They are needed for monitoring and evaluation

of disease control activities
INCIDENCE:
“No of new cases occurring in a defined
population during a specified period of time”

No of new cases of specific disease during a

given time period
Incidence=-----------------------------------------------------------x1,000
population at risk during that time

eg.,
New cases of an illness 500
Population at risk 30,000

Incidence rate= 500/30,000x1000= 16.7 per 1000 per year

Incidence rate (spells) – same disease, same person in a year

No of spells of sickness starting in a defined period

Incidence rate=--------------------------------------------------------------x1000
(spells) Mean no of persons exposed to risk in that period

Special Incidence Rates:

No of new cases of a specified disease during a
specified time interval (epidemic)
Attack rate :-------------------------------------------------------------------x100
Total population at risk during the same interval
(epidemic)
Attack Rate / Cumulated incidence - (CI)

• It is type of incidence rate used only when the

population is exposed to risk for a limited
period of time such as during an epidemic

Number of new cases of a specified disease

during a specified time interval
---------------------------------------- -----------X 100
Total population at risk during
the same interval
Secondary attack

No of exposed persons developing the disease within the

range of the incubation period following exposure to a
primary case
Incidence density - (ID)

# of new cases
ID = -------------------------------------------------- x 100
Total person-time of observation

Also known as:

• Incidence rate
• Reflects more exactly the person-time observed
Uses of incidence data
• Describe trends in diseases
• Evaluate impact of primary prevention
Programmes
• To control disease
• For research……
Etiology
Pathogenesis
Distribution of diseases and
Efficacy of preventive and therapeutic measures.
PREVALENCE

“All current cases (new and old) existing at a given

point time,
or over a period of time in a given population”

Types of prevalence
a. Point prevalence
b. Period prevalence
Point prevalence:
the no. of current cases of a disease at one point in time in
relation to a defined population
Point: a day, days, weeks…….

P= C / N
• C = # of observed cases at time ‘t’
• N = Population size at time ‘t’

Point prevalence can be made specific for age, sex and other
relevant factors
Example of point prevalence
• 150 children in a school
• Screening for refractory errors at time “t”
• 15 children require glasses
• Calculate Prevalence of refractory errors
Period prevalence:

Frequency of all current cases existing during a defined

period of time

PP = C + I / N
• C = # of prevalent cases at the beginning of the time
period

• I = # of incident cases that develop during the period

• N = size of the population for this same time period

Example of period prevalence
• Population of 150 persons
• Follow up for one year
• 25 had a disease of interest at the beginning
• Another 15 new cases developed during the
year

Calculate Point prevalence

 Factors influencing prevalence
• If the disease is short, the prevalence is
reduced
The prevalence of sudden infant death = 0

• If the disease is long, the prevalence is

increased
Rare lifelong disease can accumulate to build up
a large prevalence
Causes of increase of prevalence

• Long duration
• Low cure rate
• Low case fatality
• Increase in new cases
• Immigration of patients
• Improved detection
• Emigration of healthy people
Causes of decrease of prevalence

• Shorter duration
• High cure rate
• High case fatality
• Decrease in new cases
• Emigration of patients
• Improved cure rate
• Immigration of healthy people
Uses of prevalence data

• Assessing health care needs

• Planning health services

• Measure occurrence of conditions with gradual

onset

• Study chronic diseases

Limitations of Prevalence

 It is not the ideal measure for studying disease

etiology or causation
Patterns of incidence and prevalence

Prevalence = incidence x duration (P=I x D)

High prevalence and low incidence

e.g., Diabetes Mellitus

Low prevalence and high incidence

e.g., Common cold