Bambang Udji Djoko Rianto

2020
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 Understand sort of measurements in relation
to health problem
 The use of appropriate measurement when
dealing with health problem in population

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 To understand any of disease measurements
 To know how important the disease
measurement as evidence
 To be able to conduct disease measurement
 To be able to read and interpret disease
measurement

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 Quantify risk in several ways
 Use of limitation of common epidemiologic
measures of RISK
 Categories in measurement:
1. RATES
2. RATIOS
3. PROPORTION

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An expression in which numerator is always
included in the denominator
A rate may be a proportion when numerator is
derived from the denominator
A rate must include the period of time over
which the events occurred; proportion do not
require time

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 When RATES become evidence? What kind
of rate do we want?
 Rate is to measure the magnitude of disease
in a populationWhat do we want to know
further?
 Who? Why? When? Where? How?
 Is there any association between the disease
with any particular variable?

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 What is the denominator? Population at risk?
 How the count was taken? Any reporting
problems?
 What period of time is involved? What is the
duration of exposure of the population?

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 RATES:
 Measuring the occurrence of some events (X) in a
given time, in a population at risk (Y)
 X/Y.% per time unit

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 Risk of developing a condition
 Have predictive value for the group in a
steady host, agent, and environment
 Not necessarily predictive for an individual in
the group

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 Point prevalence: measure the frequency of
all current cases of a disease at a given
instant in time
 Period prevalence: measure the frequency of
all current cases of disease in a specified
period of time

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 Chronic disease—work loads—planning manpower
and facilities (mental illness)
 Used to express the burden of some attribute/
condition in a population
 Used instead of incidence if not available
 In a series of cross-sectional studies do not permit
etiologic inferences or estimate risk
 Duration affects prevalence P1-----------P2
 Denominator= total population

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 Incidence: frequency of new cases in the
population at risk during a specified period of
time
 Attack rate: is incidence rate used for
exposed population observed for limited
period of time (e.g in epidemic)

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 Fundamental tool for etiological and studies for
acute and chronic disease due to direct indicator of
risk measures true rate
 Direct measure probability of risk
 Comparison of incidence in one or more factors
analyzed to see whether risk factor or not
 Is more useful measure of risk
 Denominator = population at risk

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 INCIDENCE  PREVALENCE
 Health administrator?  Estimate the magnitude
Clues (petunjuk of health problems
membuktikan) of etiology  Identify potential high
if there is exposure prior to risk target population
disease
 Decreasesuccess of
control program?
 Increasefailures; find
better diagnostic

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 Deaths(D):
 Due to disease X (Dx)
 Due to Y among cases with disease X (Dxy)
 Among person who do not have disease X (Dy)
 D = Dx + D xy + Dy

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 Rates:
▪ Mortality rates: disease X in the total population (Dx +
Dxy)
▪ Fatality rates: mortality among cases with X
▪ Death rates: all disease among total population
 Probability

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 Expresses a relation between a numerator (x)
and a denominator (y) in which the events or
items counted as (x) are not necessarily
derived from (y)
 X/Y

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 X/Y
 X is number of events not necessarily a portion of
Y
 Y is the number of events or items counted not
necessarily a population exposed to the risk
 Ratio 1-100%; a period of time may be used

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 MATERNAL MORTALITY RATE? DEFINE!!!:
 NUMERATOR ??
 DENOMINATOR??

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 MATERNAL MORTALITY RATE:
Death from puerperal (demam pasca partus)
causes during pregnancy within 90 days of
delivery or completion of pregnancy in a calendar
year
_____________________________________
1000 live births at that year (not pop. at risk)
denominator excludes pregnancies which do not
cause a live birth and ectopic pregnancies.
Consequence? It is a RATIO
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 INFANT MORTALITY RATE:
death under 1 year from any causes during a
calendar year
_____________________________________
1000 live births in that calendar year

It is not a true Rate but a Ratio

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 RATES AND RATIO whose denominator
are population at risk do not distinguish
illness among those exposed from illness due
to exposure

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 RATES AND RATIO do not provide direct
answer to basic question, which is, how much
excess disease a factor such as smoking
might produce in the population? OR how
much the disease might be prevented?

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 Risk
 Risk Difference
 Relative Risk (Excess Risk, Attributable Risk)
 Attributable Risk Percent
 Risk Ratio (Cumulative incidence ratio;relative risk)
 Odds Ratio (Cross-product ratio; Relative Odds)

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 Pos+ Neg -
Exposed a b h1
(a+b)
Not Exp. c d h0
(c+d)
V1 V0 a+b+c+d
(a+c) (b+d)

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 Risk Difference= R1-R0= a/h1-c/h0
 Risk Ratio (RR)= R1/R0=a/h1:c/h0
 Odds Ratio (OR)
 Cohorta/b:c/d=ad/bc (disease odds ratio)
 Case-Control exposure odds ratio= a/c:b/d=
ad/bc

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Death rate from a disease among
exposed
__________________________
Death rate from a disease among
non-exposed
An index of the strength of association
(2 folds, 3 folds, 4 folds differences)

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 Person Person Total
With without
TB TB
Alcoholic 40 10 50

Non- 10 90 100
alcoholic
50 100 150

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 Incidence rate
 TB in alcoholic: 40/50 = 80 per 100/year
 TB in non-alcoholic: 10/100 = 10 per 100/year
 Relative (Incidence) Risk= 80:10 = 8.0

 What Clinical Epidemiologist should say?

Only suggest need proof (bukti)!!

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 Death rate from the disease among exposed MINUS
death rate from the disease among non-exposed
80 per 100-10 per 100= 70 per 100/year
 Att.Risk describes the excess rate of disease above
the baseline of disease that would be present if the
population had not been exposed to the factor of
interest
 Shows the death rate occurring due to the presence
of the suspected cause
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 Death rate from the disease among exposed
MINUS death rate from the disease among
non-exposed, then devided by death rate
among exposed  80 per 100-10 per 100= 70
per 100/year, then devided by 80 per 100= (80-
10):80= 70/80 X 100%= 87.5%

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ARP= 87.5%  means that 87.5% of the
cases would have been prevented if not
exposed to the risk factor

Clinical examples ??

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 The Attributable Risk DIVIDED by the rate among
exposed persons:
 (death rate among exposed MINUS death
rate among non-exposed)
-------------------------------------------- X 100
(death rate among exposed)

ARP= (80 per 100-10 per 100): (80 per 100) X 100 =
87.5%amount of disease might be eliminated if the
factor under study is controlled/eliminated
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 Relative Risk >>1.0 (greatly in excess of 1.0)
and low absolute risk?:
 Strong association between disease and a
suspected cause
 Rare disease only few people are likely to be
affected
 E.g. thrombophlebitis vs oral contraceptive

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 Relative Risk slightly in excess of 1.0 and a
common disease having a high incidence rate?
 Low association between disease and suspected cause
 High incidence rate means common disease and
therefore great potential for benefiting the general level
of health in the population
 E.g. smoking vs coronary thrombosis

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 Relative Risk greatly in excess of 1.0 and ARP
greater than 60?
 The factor is likely to be a cause of the disease
 The benefit of eliminating the cause have large
effect on the general level of health
 e.g lung cancer

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 Relative Risk >>1.0 (greatly in excess of 1.0) and low
absolute risk?
 Relative Risk slightly in excess of 1.0 and a common
disease having a high incidence rate?
 Relative Risk greatly in excess of 1.0 and ARP
greater than 60?
 Relative Risk below 1.0 (there is no excess of disease
due to exposure to the factor and not strongly
associated) ?

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Factors Diseased Not- Total
diseased
A 2 8 10
B 4 1 5
C 3 4 7
D 1 2 3
E 4 7 11

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Factors Diseased Total Risks
exposed
A 2 10 2/10=.2
B 4 5 4/5=.8
C 3 7 3/7=.42
D 1 3 1/3=.33
E 4 11 4/11=.36

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Factors Diseased Total Risk
exposed
A 3 5 3/5=.6
B 1 10 1/10=.1
C 2 8 2/8=.25
D 4 12 4/12=.3
3
E 1 4 ¼=.25

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F RR = Risk exposed /not exposed
A 0.2/0.6=0.33 0: protective
B 0.8/0.1=8.0>>1 : high association
C 0.43/0.25=1.72 >1: some association
D 0.33/0.36 =0.93 +/- 1: same risk not the
cause
E 0.36/0.25 =1.44 +/- 1

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F RR 95% Conf. Interval
A 0.2/0.6=0.33 (0.1 – 0.5)
B 0.8/0.1=8 (7.8 – 8.8)
C 0.43/0.25=1.72 (1.2 – 1.9)
D 0.33/0.36 =0.93 (0.6 – 1.2)
E 0.36/0.25 =1.44 (0.9 – 2.1)

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MYOCARDIAL INFARCT AND ORAL CONTROACEPTION

Recent use No use

OC

MI 29 135
No MI 205 1607
________________________
234 1742

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 Age specific use of OC
 Age MI Control
▪ 25-29 67 22
▪ 30-34 43 8
▪ 35-39 11 7
▪ 40-44 8 2
▪ 45-49 6 2

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 Age OC use MI Control OR
 25-29 Yes 4 62 7.2
No 2 224
 25-29 Yes 9 33 8.4
No 12 390
 35-39 Yes 4 26 1.5
No 33 330
 40-44 Yes 6 9 3.7
No 65 362
 45-49 Yes 6 5 3.9
No 93 301

CRUDE OR= 1.7 ; aOR= 4.0

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 Thank you

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