Basic measurement in epidemiology

Leulseged Alem ( RN,BSC, MPH/E) 1

 Epidemiology is a quantitative Science applied to describe
groups of persons
 The ability for any epidemiological investigation is the
ability to quantify the occurrence of disease

 Measurement of disease frequency:

 Rate
 Ratio
 Proportion
 Common Measurement of disease occurrence:
• Prevalence
• Incidence

Leulseged Alem ( RN,BSC, MPH/E) 2

MEASURMENT OF DISEASE OCCURANCE:
• Number of cases in a given community can give more sense if
they are related to the size of the population
 Population size can be determined by calculating
• Ratios
• Proportions
• Rates
They are useful to provide :
 Information about probability of occurrence of health events
 Population at high risk of acquiring the disease
 In designing appropriate Public Health Intervention

Leulseged Alem ( RN,BSC, MPH/E) 3

Raw numbers (counts):
 The simplest and most performed quantitative measurement in
Epidemiology

 The number of persons in the group studded who have particular

disease or particular characteristic
 E.g. number of student
 Used to:
 Monitor occurrence of infectious diseases
 Draw an epidemiologic curve
 Develop plan

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Ratio:
 Expresses relation ship between two items in the form of X:Y
 Compares relative frequency of occurrence of some event to
the other event
E.g. The female to male ratio of a disease in the school
Proportion:
 It is a type of ratio (expressed as a percent) in which X is
included in Y
 Numerator is included in the denominator.
E.g male/both sexes (proportion of male in community)
Percentage
 (number per hundred) is one of the most common ways of
expressing proportions

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Number per 1000 or per 100,000 and per 1,000,000, or any other
convenient base may also be used

Rate: Measures the occurrence of an event in a population over time

 It can be seen as a proportion with a time dimension
 It measures the occurrence of deaths (mortality), births ( natality)
 Rates are often proportions

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Rates must:
 Include persons in the denominator who reflect the population
from which the cases in numerator arose
 Include counts in the numerator which are for the same time
period as those from the denominator
 Includes only persons in the denominator who are " at risk" for
the event

• E.g. measles cases in under five in 2005

Under five children in 2005

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• Common measures of disease frequency:
• Measurement of disease is more difficult than that of death
because:
 Sickness may not be easily recognizable.
 Sickness may occur repeatedly in one person.
 Person may suffer from many diseases at one time.
• The frequency of health related events are measured by Risk,
Prevalence and Incidence rate.
• Risk (cumulative incidence): the likely hood that a person will
contract a disease.
• Group of people who have potential of getting disease
Risk = New cases occurred during a given time period
Population at risk during the same period

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 Measurements of morbidity
Morbidity rates are rates used to quantify the occurrence of disease.
Measures of morbidity include
1. Incidence
2.Prevalence

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Incidence:
 The number of new cases or events occurring in a defined
population with in a given period of time.

 It is the best indicator of whether a condition is decreasing,

increasing or remaining static.

Leulseged Alem ( RN,BSC, MPH/E) 10

 Cont..
Incidence rate: is a rate which measures the occurrence of new
cases of disease in the defined population during a specified
period of time
Incidence rate = No of new cases at observation period
person at risk during the same time observant.

Ex-In sene 2000 there were 50 new cases for relapsing fever in
kebele x total population was 5000
Incidence rate = 50/5000 * 1000= 10 new case per 1000
population

Leulseged Alem ( RN,BSC, MPH/E) 11

 Incidence

The critical element in the definition of incidence is new cases of

disease, then population at risk.

Because incidence is a measure of new events (i.e. transition from

a non-diseased to a diseased state), incidence is a measure of risk.

For incidence to be a measure of risk we must specify a period of

time and we must know that all of the individuals in the group
represented by the denominator have been followed up for that
entire period.

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 Incidence
The choice of time period is arbitrary:
We could calculate incidence rate in one week, one month,
one year, 5 years, and so on.

Incidence rates can be used to make statements about

the risk of disease.

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 Type of incidence

1. Cumulative Incidence (CI): is the proportion of people

who become diseased during a specified period of time and is
calculated as:

CI= Number of new cases during a specified period of time

Total Population at risk in the specified period of time

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 Cont`d

2. Incidence Density/person-time rate

• Measures the rate at which new cases of disease occur in the
population at risk during a defined period
• The population at risk is dynamic and each person in the population
contributes the amount of time that they remained under
observation and free from disease (person-time)

Incidence Density = number of new cases of disease in specified period x10 n

Total person-time of observation

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 Cont`d
• The numerator is still the number of new cases, but the
denominator is the sum of the time each person is observed,
totalled for all persons.
• For incidence density, the denominator is measured in person-
time units rather than persons at risk of developing the disease

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 Cont`d

What is person-time for?

1. 100 people followed for 1 year each
2. 10 people followed for 10 years each
3. 50 people followed for 1 year each plus 25 people followed
for 2 years each
4. Time unit=month, year, day; person-time=person-year, person-
month,

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 Cont`d
• Person-time rates are often used in cohort (follow-up) studies
of diseases with long incubation or latency periods, such as
occupationally related diseases, AIDS, and chronic diseases.

• Total person-time for the denominator is computed by either…

– Summing the amount of person-time contributed by each
person in the population during the study period, or

Leulseged Alem ( RN,BSC, MPH/E) 18

 Cont’d

– Multiplying the average size of the population at the mid-point

of the study period times the number of years representing the
total study period

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 Cont’d
Example
• Investigators enrolled 2,100 men in a study and followed them
over 4 years to determine the rate of heart disease.
• We assume that persons diagnosed with disease and those lost
to follow-up were disease-free for half of the year, and thus
contribute ½ year to the denominator.

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 Cont’d
• Initial enrolment: 2,100 men free of disease
– After 1 year: 2,000 disease-free, 0 with disease, 100 lost to
follow-up
– After 2 years: 1,900 disease-free, 1 with disease, 99 lost to
follow-up
– After 3 years: 1,100 disease-free, 7 with disease, 793 lost to
follow-up
– After 4 years: 700 disease-free, 8 with disease, 392 lost to
follow-up 21
Leulseged Alem ( RN,BSC, MPH/E)
 Continued…

1. Identify x: x = cases diagnosed = 1 + 7 + 8 = 16

2. Calculate y, the person-years of observation:

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 Alternative Methods

• A second way to calculate the person-years of observation is to

turn the data around to reflect how many people were followed
for how many years, as follows:
• 700 men x 4.0 years = 2,800 person-years

• 8 + 392 = 400 menx3.5 years = 1,400 person-years

• 7 + 793 = 800 menx2.5 years = 2,000 person-years

• 1 + 99 = 100 menx1.5 years = 150 person-years

• 0 + 100 = 100 menx0.5 years

Leulseged Alem= 50 person-years
( RN,BSC, MPH/E) 23
 Cont`d

• Total = 6,400 person-years of observation

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 Special Types of Incidence: Attack Rate
Narrowly defined population
Observed for a limited time (e.g. epidemic).
oUsually expressed as a percent.

(primary) Attack rate =

Number of new cases among the
population during the period x 100
Population at risk at the
beginning of the period

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 Attack Rate: Example

Of 75 persons who attended a church picnic, 46 subsequently

developed gastroenteritis.
a) Calculate the attack rate of gastroenteritis :
x = Cases of gastroenteritis occurring within the incubation period
for gastroenteritis among persons who attended the picnic = 46
y = Number of persons at the picnic = 75
AR= 46/75 x 100%

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 Cont`d

Secondary attack rate: is an important measure of spread of

disease among contacts of an index case.
• It is often defined for exposure to an infective within some
small population unit, such as household, classroom, prison, or
school bus.

Leulseged Alem ( RN,BSC, MPH/E) 27

 Cont`d
• NB: the index cases are not included in both the numerator
and denominator.
In other ways,

Secondary attack rate = Total number of cases – Index cases

No. of susceptible – Index cases

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 Cont`d
• The data required for estimating secondary attack rate are:
 the time of onset of disease for each case in the household;
 knowledge of who is susceptible;
 estimates/assumptions about minimum and maximum
incubation periods;
 the latent period; and the maximum time that a person
remains infectious; sometimes it can assumed that the onset
of symptoms coincides with the onset of infectiousness and
that there are no in apparent cases.
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 Incidence measures rapidity with which newly diagnosed patients
develop over time.
 Most common way of measuring and comparing the frequency of
disease in populations.
Uses of Incidence
 For etiologic studies of both acute and chronic diseases.
 Direct indicator of risk
 Helps to generate hypothesis

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Prevalence:

The amount of disease that is already present in a population

Prevalence Rate
= all new & pre-existed case at given time period X
Population during the same time period
It is the total number of newly occurring plus pre existing cases in
a given population with in a specified period of time.

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Prevalence =Incidence + Duration

I = New
Key
P=Prevalence
P = All I= Incidence
D= Death
R= Recovery
D R

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Prevalence Uses
• To determine work load
• Planning of health care services & human resources
• For monitoring of diseases control and prevention programs

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Types of prevalence
◦ Point prevalence
◦ Periodic prevalence
Point prevalence: Measures proportion of a population with a
certain condition at a given point in time

Point prevalence rate = Existing cases at one point in time x K

Total population

 e.g., prevalence of HIV infections in Gondar on January 1,

2005.

 prevalence of depression among widows/widowers 6 months

after the death of a spouse.

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 Prevalence question

Interview question Type of measure:

Do you currently have Point prevalence
asthma??
Have you had asthma in the Period prevalence
last 10 years??
Have you ever had asthma? Lifetime
prevalence

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

Improved diagnostic facilities

(better reporting)
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Period prevalence:
• Measures the proportion of a population that is affected with a
certain conditions during a specified period of time

Period prevalence = Existing cases over a period of time x K

Total Population

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Leulseged Alem ( RN,BSC, MPH/E) 38
 Reading assignment
Measures of Mortality
o Crude rates
o Specific rates
o Standardized or adjusted rates
Source of data in epidemiology
Census
Vital statistics
Health service records

Leulseged Alem ( RN,BSC, MPH/E) 39

Thank you

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 Measures of Mortality
Mortality rates could be classified into three main types:
o Crude rates
o Specific rates
o Standardized or adjusted rates

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Crude, specific and adjusted mortality rates
Any rate can be expressed for a total population (crude or
adjusted rates) or for a population subgroup (specific rates).

Crude rates: are summary rates based on the actual number of

events in the total population over a given period of time, e.g.
Crude Birth Rate, Crude Death Rate (CDR).

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Specific rates: are rates of health events in specific
subgroups of the population (a specific age group, sex,
race, marital status, etc) over a given period of time, e.g.
Infant Mortality Rate (IMR), Maternal Mortality rate.
To be able to clearly understand what differences exist
between crude and specific rates in general, the
discussion will be about CDRs and specific death rates
(particularly age specific rates).

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Crude death rate gives a summary result of the total population,
while age specific rate gives separate rate for the different age
strata.

Crude death rate is not appropriate for comparison of the risk of

death in different locations. While comparison of risk of death for
each age group is possible by age specific death rate.

Crude death rate gives lamped information; specific age groups

at high risk of death can’t be identified separately.
In the contrary, Age specific death rates give detailed information.

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Adjusted rates/standardization

In search of a rate which can give a summary rate and at the
same time allows interpretation as to the risk of disease or death
of a population making comparison of different populations
possible, epidemiologists have come up with a statistically
created rate called Adjusted rate.

Adjusted rate is a rate, which overcomes the limitations of

both crude rates as well as specific rates. Rates can be adjusted
by sex, race or age, etc but the most common adjustment is by
age.

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• Standardization aims to increase comparability
between exposure groups.it can be direct or indirect.
• In the direct method weights/population come from
the standard population.
• In the indirect method rates come from the
standard population.

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Direct Standardization
• Would the overall prevalence be different if
the population distribution was the same?
• If the populations is compared to a certain
standard population.
– A standard population is defined as one for
which the numbers in each age and sex
group are known.

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 Direct Standardization
Exposure Age group
Low 15-44 45-64 65+ Total
Population 10 20 70 100
Cases 1 5 35 41
Prevalence 0.10 0.25 0.50 0.41
Adjusted P 41/100 0.41
Mediu Population 30 40 30 100
m
Observed Cases 5 18 18 41
Prevalence 0.17 0.45 0.60 0.41
Expected cases 0.17*10=1.7 0.45*20=9 0.60*7 53
0=42

Adjusted P 53/100 0.53

High Population 70 20 10 100
Observed Cases 21 12 8 41
Prevalence 0.30 0.60 0.80 0.41
Expected cases 0.30*10=3 0.6*2=12 0.8*7=56 71
Adjusted P 71/100 0.71
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Comparisons are performed using the low exposure
group population as standard.
SRR (%) = Adjusted prevalence/Observed prevalence x
100
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 Indirect Standardization
• Would the overall prevalence be different if

the populations had the same age-specific

rates?

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Leulseged Alem ( RN,BSC, MPH/E) 51
Comparisons are performed using the low exposure group
prevalence (rate) as standard.
SMR= Observed cases/Expected Cases x 100

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Measures of Mortality

Measures of mortality are used to quantify the occurrence of deaths

in a defined population during a specified period. Some of the
measures include:

How to calculate the different mortality rates and ratios:

a) Crude Death Rate = Total number of deaths in a year X 1000

Average (or midyear) population

Leulseged Alem ( RN,BSC, MPH/E) 53

b) Age specific Mortality Rate =
No. of deaths in a specific age in a year X 1000
Average (midyear) population of the specific age group

c) Sex specific Mortality Rate =

No. of deaths in a specific sex in a year X 1000
Average (midyear) population of the specific sex

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Neonatal Mortality Rate

= No. of deaths of children less than 4 weeks old in a yr X 1000

No. of live births in same year

Infant Mortality Rate (IMR)

= No. of deaths of children less than 1 year old in a year X 1000
No. of live births in the same year

Maternal Mortality ratio (MMR)

No of deaths of women from pregrnancy related causes in yr
  100,000
No of live births in the same year

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• Some commonly used specific death rate:
• Infant Mortality Rate: the number of
deaths of infants up to the age of one year
per 1000 live-birth in a given year

IMR = NO of deaths < 1 yrs of age x 1000

No of live birth during the same period

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• Use
– To measure health status of the community
– To see availability and effective use of health
care
• E.g. Perinatal cares
• Neonatal Mortality Rate (NMR)
NMR = No death up to 28 days of age in calendar yr x1000
Number of live births in the same calendar year

• Use: To see condition of the fetus and pre and

post delivery

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Child Mortality rate (CMR)
• Number of deaths at ages of 1-4 yrs in a given area per
1000 children in that age group at the mid point of the year
concerned

CMR = No of deaths of children 1-4 yrs of age during a yr x 1000

# of children 1-4 yrs of age at the middle of the yr

• Use: Main environmental factor affecting the children:

• Nutrition
• Sanitation
• Communicable Disease of children
• Accident occurring in and around the home
• It is sensitive indicator socioeconomic development in a
community
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Under Five Mortality Rate:
• Is the number of deaths of children under five
years of age per 1000 children age under 5 years in
a calendar year
• U5MR = No of deaths U5 yrs of age in the given yr x 1000
# Of children U5 yrs of age in the middle of the yr

• This rate combines both infant and child mortality

rate

Leulseged Alem ( RN,BSC, MPH/E) 59

 References

• Charles H. Hennekens, DrPH. Julie E. Buring, Sc D.

Epidemiology in medicine. Lippincott Williams and Wilkins,
USA.
• Kifle Wolde Michael, Yigzaw Kebede, Kidist Lulu.
Epidemiology for health science students: Lecture Note Series.
• Lilienfield, MA. Lilienfield ED. Foundations of epidemiology,
1980, Oxford University Press, New York.
• Zein Ahmed Zein and H. Kloos. The Ecology of Health and
Disease in Ethiopia, 1993.
• Barker DJP. Practical Epidemiology, 1976, Churchill Living
Stone, Singapore.
Leulseged Alem ( RN,BSC, MPH/E) 60
 Cont`d

• Abramson JH. Survey Methods in Community Medicine. 1984,

Churchill Living Stone, New York.
• Last, Maxcy- Rosenau- Preventive medicine and Public Health,
1986, Appleton century- Crofts- Norwalk, Connecticut.
• Robinson, D.(ed), Epidemiology and the Community Control of
Disease in warm Climate Countries, 1985, Churchill
Livingstone, New York.
• Fletcher. Principles and Practices of Epidemiology. 1992,
EMDPA, Addis Ababa, Ethiopia.
• Shiferaw M. Fenta H. Epidemiology, A Manual for Students and
Health Workers in Ethiopia.

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