MEASUREMENT
By Misganaw T.
04/10/2024 By Misganaw T.(BSc in Nursing) 1
Measures of Disease Occurrence
The number of cases in a given community can
give more epidemiologic sense if they are related
to the size of the population.
Such tie of the number of cases with the
population size can be determined by calculating
ratios, proportions, and rates.
They are important in designing appropriate
public health interventions.
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Measures of Disease Occurrence
Ratio: the value of x and y may be completely
independent, or x may be included in y.
Example: Male: Female (male to female ratio)
Proportion: is a ratio (expressed as a percent)
in which x is included in y.
Example: Male/Both sexes (proportion of male
in a community)
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Measures of Disease Occurrence
Rate: measures the occurrence of an event in
a population over time.
The time component is important in the
definition.
Rates are often proportions.
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Measures of Disease Occurrence
Rates must:
include persons in the denominator who reflect
the population from which the cases in the
numerator arose;
include counts in the numerator which are for the
same time period as those from the denominator
include only persons in the denominator who are
"at risk" for the event.
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Measures of Disease Occurrence
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Ratio
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Morbidity
• The extent of illness, injury or disability in a defined
population
Incidence of a disease (Incidence rate)
• The number of new cases of a disease that occur during a
specified time period (numerator) in a population at risk for
developing the disease (denominator)
Prevalence of a disease (Prevalence rate)
• The number of total cases of disease present at a particular
time (numerator) in a specific population (denominator)
Risk
• The likelihood that an individual will contract a disease
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Incidence rate
Incidence rates are the most common way of
measuring and comparing the frequency of
disease in populations.
We use incidence rates instead of raw numbers for
comparing disease occurrence in different
populations because rates adjust for differences in
population sizes.
The incidence rate expresses the probability or risk
of illness in a population over a period of time.
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Incidence rate
Since incidence is a measure of risk, when one
population has a higher incidence of disease
than another, we say that the first population is at a
higher risk of developing disease than the
second, all other factors being equal.
We can also express this by saying that the first
population is a high-risk group relative to the
second population
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Incidence rate
There are three key ideas in this definition.
First, incidence measures new disease events.
For diseases that can occur more than once, it
usually measures the first occurrence of the
disease
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Incidence rate
Second, new cases of disease are measured in a
candidate population, which is a population of
people who are “at risk” of getting the disease.
Someone is at risk because he or she has the
appropriate body organ, is not immune, and so
forth
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Incidence rate
Third, incidence takes into account the specific
amount of time that the members of the
population are followed until they develop the
disease.
Because incidence measures a person’s transition
from a healthy to a disease state, time must pass for
this change to occur and be observed.
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An incidence rate (sometimes referred to simply as
incidence) is a measure of the frequency with which
an event, such as a new case of illness, occurs in a
population over a period of time.
Incidence rate =
new cases occurring during a given time period× 10n
population at risk during the same time period
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Incidence rate
The numerator of an incidence rate should
reflect new cases of disease which occurred or
were diagnosed during the specified period.
The numerator should not include cases which
occurred or were diagnosed earlier.
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Incidence rate
Notice that the denominator is the population at risk.
This means that persons who are included in the
denominator should be able to develop the disease
that is being described during the time period covered.
Unfortunately, unless we conduct a special study, we
usually cannot identify and eliminate persons who are
not susceptible to the disease from available
population data
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Incidence rate
in practice, we usually use Census population counts
or estimates for the midpoint of the time period
under consideration
If the population being studied is small and very
specific, we can and should use exact denominator
data
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Depending on the circumstances, the most
appropriate denominator will be one of the
following:
average size of the population over the time period
size of the population (either total or at risk) at the
middle of the time period
size of the population at the start of the time
period
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INCIDENCE RATE
divided into two types:
1. Cumulative incidence rate
2. Incidence density
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1. Cumulative incidence rate:
Number of new cases of disease occurring
over a specified period of time in a
population at risk at the beginning of the
interval.
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EXAMPLE OF CUMULATIVE
INCIDENCE RATE
If we count all new cases of influenza
occurring in MSU undergraduates from
September 1, 1997 - August 31, 1998, and
we take as the denominator all
undergraduates enrolled in September 1,
1997, we would be describing the
cumulative incidence rate of influenza.
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Incidence proportion (“cumulative
incidence”)
Number of new cases
5-month CI = –––––––––––––––––––
Population at risk
Incidence proportion estimates risk.
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2. Incidence density:
Number of new cases of disease
occurring over a specified period
of time in a population at risk
throughout the interval.
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Incidence density
ID =
Number of new cases of disease
Person-time of observation in candidate population
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Incidence density
Note that the numerator for incidence rate is
identical to that of cumulative incidence.
The difference between the two measures lies in the
denominator.
The incidence rate’s denominator integrates time
(t), and so it is a true rate.
Thus, its dimension is 1/t or t 1, and its possible
values range from zero to infinity
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Incidence density
An incidence rate of infinity is possible if all
members of a population die instantaneously
Person-time is accrued only while the candidate is being
followed.
Accrual of person-time stops when the person dies or is
lost to follow-up (such as when a person moves away
from a community).
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Incidence density …
The incidence rate can be calculated for either a
fixed or dynamic population.
However, because it directly takes into account
population changes (such as migration, birth, and
death), it is especially useful as a measure of the
transition between health and disease in dynamic
populations
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Prevalence rate
While incidence measures the frequency with
which new disease develops,
prevalence measures the frequency of existing
disease.
It is simply defined as the proportion of the total
population that is diseased.
There are three types of prevalence measures—
point prevalence , period prevalence and life time
prevalence that relate prevalence to different
amounts of time.
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Point prevalence refers to the proportion of the
population that is diseased at a single point in time
and can be thought of as a single snapshot of the
population.
The point can be either a particular calendar date
such as December 1, 2005 or a point in
someone’s life such as college graduation
Number of existing cases of disease At a point in time
Number in total population
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Prevalence rate
Period prevalence refers to the proportion of the
population that is diseased during a specified duration of
time, such as during the year 2005
The period prevalence includes the number of cases that
were present at the start of the period (for example,
January 1, 2005) as well as the number that developed
during the period
(for example, January 2 through December 31, 2005).
It may be helpful to think of period prevalence as derived
from a series of snapshots.
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Period prevalence
PP
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Prevalence rate
Note that the numerator (existing cases) is a subset of the
denominator (total population).
Unlike the numerator for the two incidence measures, the
prevalence numerator includes all currently living cases
regardless of when they first developed.
The denominator includes everyone in the population—
sick, healthy, at risk, and not at risk.
Because prevalence is a proportion, it is dimensionless and
its possible values range from zero to one, or 0 to 100%
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Relationship Between Prevalence
and Incidence
Prevalence depends on the rate at which new cases of
disease develop (the incidence rate) as well as the
duration or length of time that individuals have the
disease.
The duration of a disease starts at the time of diagnosis
and ends when the person either is cured or dies.
Mathematically, the relationship between prevalence
and incidence is as follows:
P/(1- P) = IR * D
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USES OF INCIDENCE AND PREVALENCE
1. Incidence is generally used for acutely acquired
diseases, prevalence is used for more permanent
states, conditions or attributes of ill-health.
2. 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.
3. Incidence always requires a duration, prevalence
may or may not.
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4. In incidence, the unit of analysis is the event,
in prevalence, it is the person. Thus
incidence may exceed 100% (e.g. annual
incidence of colds) unless a convention is
adopted to count only first episodes of an
illness that can occur more than once.
5. Prevalence can never exceed 100%.
6. Incidence generally requires an initial
disease-free interval before counting starts,
because incidence is measured only in those
at-risk of disease.
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Uses of prevalence
Prevalence rates are important particularly
for:
Chronic disease studies
Planning health facilities and manpower
Monitoring disease control programs
Tracking changes in disease patterns over
time
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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 By
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facilities
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(better reporting)
Measures of Mortality
Mortality is a term which means “death” or
describes death and related issues
A mortality rate is a measure of the frequency of
occurrence of death in a defined population
during a specified interval. For a defined
population, over a specified period of time
Mortality rate =
deaths occurred during the given time period
size of the population among the death occurred
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Mortality Cont …
1. Annual Death Rates (crude death rate)
• “General” (crude) mortality rate
– a population group exposed to risk of death
– a time period
• Crude Mortality Rate = # of deaths occurring in that population during
that period of time
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Mortality Cont …
2. Age-Specific Death Rate (ASDR):
• is defined as total number of deaths occurring
in a specified age group of the population of a
defined area during a specified period per 1000
midyear population of the same age group of
the same area during the same period.
• ASDR×1000
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Mortality Cont …
3. Cause Specific Death Ratio and Rate:
• A cause specific death ratio (proportionate mortality
ratio) represents the percent of all deaths due to a
particular cause or group of causes.
• CSD ratio for cause C×1000
where
o Dc is total deaths from cause c and
o Dt is total deaths from all causes in a specified time period.
• Cause Specific Death Rate (CSDR) is the number of
deaths form cause c during a year per 1000 of the
midyear population, i.e.
• CSDR c×1000
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Mortality Cont …
4. Infant Mortality Rate (IMR): measures the risk of
dying during infancy (i.e. the first age of life), and is
defined as:
• Infant Mortality rate: the probability of dying between
birth and age oneyear per 1000 live births.
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Mortality Cont …
5. Neonatal Mortality Rate (NMR): measures
the risk of dying within 28 days of birth. It is
defined as
• NMR×1000
6. Post - Neonatal Mortality Rate (PNMR): Measures
the risk of dying during infancy after the first 4 weeks
of life, and is defined as:
• PNMR×1000
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Mortality Cont …
7. Maternal Mortality Rate (MMR): is defined as
the number of deaths of mothers (Dm) due to
maternal causes, i.e. complications of pregnancy,
child birth, and puerperium, per 100,000 live
births during a year, i.e.
• MMR×100,000
• MMR measures the risk of dying of mothers from
maternal causes.
• Ideally the denominator should include all
deliveries and abortions.
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MEASURES OF FERTILITY
1. Crude Birth Rate (CBR): is the number of live
births in a year per 1000 midyear population in
the same year.
CBR×1000
• (*) Live Birth is the complete expulsion or
extraction from its mother as a product of
conception irrespective of the duration of
pregnancy, which after such separation show
evidence of life, (like breathing, pulsation of the
heart, etc.)
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FERTILITY cont…
2. General Fertility Rate (GFR): is the number of
births in a specified period per 1000 women
aged 15-49 year; i.e.
• GFR×1000
• GFR is general because we are considering all females in
the age group 15-49 without restricting to those who
have child (children).
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FERTILITY cont…
3. Age Specific Fertility Rate (ASFR): is the
number of live births in a specified period per
1000 women of a given age or age group.
• ASFR×1000
• ASFR is used to measure the reproductivity performance of a
given age, thus showing variation in fertility by age.
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FERTILITY cont…
4. Total Fertility Rate (TFR): is the sum of all
age specific fertility rates for each year of age
from 15-49 years.
• It is the average number of children that a
synthetic (artificial) cohort (a group of persons
who share a common experience within a defined
period) of women would have at the end of
reproduction, if there were no mortality among
women of reproductive age; each woman will
live up to 49 years of age, about a total of 35
years.
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FERTILITY cont…
• TRF ×1000 for single year classification of age
• TRF=5××1000 for 5 year age group
classification
• where Bi = Bf + Bm = birth of both sex at age i
of mothers
• i = female population at age (age interval) i.
• TFR is used as a standardized index for the
overall fertility level and measures the total
number of children a cohort of women will
have at the end of their reproductive age.
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FERTILITY cont…
5. Gross Reproduction Rate (GRR): is the total
fertility rate restricted to female births only.
Here, in order to compute the rate we need the
ASFRs restricted to female births at each single
year of age.
• GRR×1000 for single year age classification
• GRR×5×1000 for 5 years age grouping
• where = (Total male and female births)
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FERTILITY cont…
6. Net reproduction rate (NRR)
• The main disadvantage of the gross reproduction
rate is that it does not take into account the fact
that not all the females will live until the end of
the reproductive period.
• In computing the net reproduction rate, mortality
of the females is taken into account.
• The net reproduction rate measures the extent to
which the females in the childbearing age-groups
are replacing themselves in the next generation.
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FERTILITY cont…
• The net reproduction rate is one in a stationary
population; a population which neither increases
nor decreases (i.e. r = 0 ).
• In most cases, NRR is expressed per woman
instead of per 1000 women.
• NRR = 1 ⇒ stationary population (i.e., 1 daughter
per woman)
• NRR < 1⇒ declining population
• NRR > 1⇒ growing population
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