Measure of morbidity and mortality

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 Concepts of Measurements
• Epidemiology is mainly a quantitative discipline,
so we should quantify health and health related
events.

• Types of Measurements:
Absolute numbers
Ratio, Proportion, Rate

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 Ratio , Proportion and Rate
Ratio
Ratio quantifies the magnitude of one occurrence or
condition to another. It expresses the relationship
between two numbers in the form of x: y or x/y
Example:
-The ratio of males to females (M:F) in this class
-The ratio of male malaria patients to female malaria
patients

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 Ratio, Proportion and Rate
• Proportion
A proportion quantifies occurrences in relation to the
populations in which these occurrences take place.
• It is a specific type of ratio in which the numerator is
included in the denominator and the result is
expressed as a percentage.
Example: The proportion of all births that was male

• x 100

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 Ratio, Proportion and Rate
• Rate - is a special form of proportion, with time
dimension .
• It measures the occurrence of an event in a
population over time.

• Example: The number of newly diagnosed pneumonia

cases in 1999 per 1000 under five children.

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 Types of rates

1. Crude rates
2. Specific rates
3. Adjusted (standardized) rates

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 Crude rates

• Are summary rates based on the actual

number of events (births, deaths, diseases) in
the total population over a given time period
– Crude birth rate (CBR) and the crude death
rate (CDR) are widely used

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 Crude rates
• Advantages • Disadvantages
• Actual summary rates • Difficult to interpret
• Calculable from due to variation in
minimum information composition (e.g. age)
• Widely used despite • Obscure significant
limitations differences in risk
between subgroups

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 Specific rates
• Apply to specific subgroups in the population,
such as a specific age group, sex and occupation
• Denominator should be the population in that
specific group
Infant Mortality Rate

Neonatal Mortality Rate

 Under Five Mortality Rate

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 Specific rates
• Advantages • Disadvantages
• The rates apply to • It is cumbersome to
homogenous subgroups compare many
• The rates are detailed subgroups of two or
and useful for more populations
epidemiological and
public health purposes.

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MEASURES OF MORBIDITY
INCIDENCE RATE:
– Cumulative Incidence

– Incidence Density
PREVALENCE RATE:
– Point Prevalence

– Period Prevalence

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 INCIDENCE RATE
• It measures the rate at which people without the
disease develop the disease during a specified
period of time.
• The incidence rate expresses the probability or risk
of illness in a population over a period of time.
• It is used to study disease aetiology

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 CUMULATIVE INCIDENCE (RISK)
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
It is a measure of the probability or risk of disease, i.e., what
proportion of the population will develop illness during the
specified time period.
Example: During a 1-year period, 10 out of 100 “at risk” persons
develop the disease of interest.
CI =10/100=0.1 or 10%
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 Incidence Rate (IR)/Incidence density
 Measures the rate at which new cases of disease occur
in the population at risk during a defined period.
IR = No. of new cases of disease during a given period
Total “person-time” of observation
 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).

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 INCIDENCE DENSITY/PERSON-TIME

 For incidence density, the denominator is measured

in person-time units rather than persons at risk of
developing the disease.
 The numerator is still the number of new cases, but
the denominator is the sum of the time each person
is observed, total for all persons.

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 INCIDENCE DENSITY/PERSON-TIME RATE…

Person Follow-up Time on Study Person Yrs.

1 <-------------------------------------> 2
2 <--------------------------------------D 2
3 <-----------------WD 1
4 <-------------------------------------------------------> 3
5 <-------------------------------------> 2
1995 1996 1997 1998
Jan. Jan. Jan. Jan.

Number of Cases 1
Person Years of Observation: 10
IR = 1 case / 10 person years of follow-up

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 Example, calculate person year contribution of the 110 persons

No. people Period at risk Person-year

contribution

50 1 year 50

40 6 months 20

20 3 months 5

110 75

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 INCIDENCE DENSITY/PERSON-TIME RATE …

• 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
 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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 INCIDENCE DENSITY/PERSON-TIME RATE…
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.
• 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
1. Identify x: x = cases diagnosed = 1 + 7 + 8 = 16
2. Calculate y, the person-years of observation:
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 Prevalence rate
• Prevalence rate measures the number of people
in a population who have a disease at a given
time. It includes both new and old cases

• Prevalence = x 100

– Numerator is number of both existing cases and new cases

– Denominator is total population of interest

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 POINT AND PERIOD PREVALENCE

 Point prevalence : Is the amount of disease present in a

population at a single point in time.
Point prevalence = All the cases of factor of interest at a given time x 10n
total population

 Period prevalence: The numerator in period prevalence

is the number of persons who had a particular disease or
attribute at any time during a particular interval (week,
month, year, decade, or any other specified time period).
Period prevalence= All cases (old and new) of the factor of interest during the time period x 10n
average population during the given period of time

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• Example: a health extension worker conducted a survey
in one of the nearby elementary schools on December 10,
2016 to know the prevalence of trachoma in that school.
The total number of students in that school was 200. The
health extension worker examined all the 200 students for
trachoma. 100 students were found to have trachoma.
Calculate the prevalence of trachoma on students

• prevalence = 100/200 x 100 = 50%

• That means 50 % of the students in that elementary
school were affected by trachoma on December 10, 2016
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EXAMPLE: Two surveys were done in the same community 12 months
apart. Of 5,000 people surveyed the first time, 25 had antibodies to
histoplasmosis. Twelve months later, 35 had antibodies, including the
original 25. Calculate the prevalence and incidence at the second survey
and compare them.
1. Prevalence at the second survey:
x = antibody positive at second survey = 35 y = population = 5,000
x/y X10n = 35/5,000 x 1,000 = 7 per 1,000
2. Incidence in the 2nd survey:
x = number of new positives in the 2nd survey = 35 - 25 = 10
y = population at risk = 5,000 - 25 = 4,975
x/y x10n = 10/4,975 x1,000 = 2 per 1,000

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 Characteristics of Prevalence
• Useful for planning (e.g. beds, clinics, workforce needs)
and for monitoring chronic disease control program.
• High prevalence  high risk (incidence)
– could reflect increased survival(improved care, long duration of
a disease – chronic diseases)
• Low prevalence doesn't necessarily mean low burden of a
disease  could reflect rapid fatal or cure process - short
duration)
• Easy to obtain need only one measurement

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Figure 1.2 Relationship between prevalence and incidence

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 Factors Influencing Ds Prevalence
Increased by: Decreased by:
Longer duration of the Shorter duration of
disease disease
Prolongation of life of
patients without cure High case-fatality rate
from disease

Increase in new cases Decrease in new cases

(increase in incidence) (decrease in incidence)

In-migration of cases In-migration of

healthy people
Out-migration of healthy
people Out-migration of cases
In-migration of susceptible
people Improved cure rate
of cases
Improved diagnostic
facilities
(better reporting) 27
 Relationship between prevalence and incidence

• Prevalence is based on both incidence

(risk) and duration of disease.
• High prevalence of a disease within a
population may reflect:
 high risk or incidence
prolonged survival without cure.

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Relationship between prevalence and incidence

Conversely, low prevalence may indicate:

low incidence
a rapidly fatal process
rapid recovery

Thus, prevalence rate is directly proportional to

both incidence rate and to the average duration
of the disease and thus expressed as
p ~ IR x D
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