ERIC NOTEBOOK SERIES

Second Edition

Incident vs. Prevalent Cases and Measures of

Occurrence
To determine which factors impact
Second Edition Authors: These prevalent cases would
health outcomes at the population include both people who have
Lorraine K. Alexander, DrPH level, epidemiologists employ a diabetes at the outset of the study
number of different study designs. year as well as any who developed
Brettania Lopes, MPH These designs are used to examine diabetes over the course of the
Kristen Ricchetti-Masterson, MSPH the relationship between exposures study.
(or determinants) and health
Karin B. Yeatts, PhD, MS outcomes. A health outcome may be Incident cases are all individuals who
a disease, condition, death, event or change in status from non-disease to
a change in health status or disease or from one state of a
behavior. For example, in addition to health outcome to another over a
diseases, we may study health specific period of time. In other words,
events such as injuries or the incidence refers to the occurrence
occurrence of an event such as of new cases.
preterm birth. Persons who
experience the outcome of interest Example
are commonly referred to as cases.
For example, in a study of incident
One of the first things to consider cases of diabetes with a one year
when developing a study is whether time period, only those who
you will measure prevalent or developed diabetes over the course
incident cases. of the one year study period are
considered incident cases.
Prevalent cases are all individuals
living with the outcome of interest
Measures of frequency
within a specified timeframe,
regardless of when that person was Prevalence
diagnosed or developed the health
Prevalence is the proportion of a
outcome.
population living with a specific health
Example outcome within a specified time. It is
In a study of prevalent cases of the only measure of occurrence
diabetes with a one year time calculated with prevalent cases. To
period, anyone who has diabetes calculate prevalence, the number of
during the one year study period prevalent cases (numerator) is divided
would be counted as a case. by the total population at risk

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 ERIC NOTEBOOK PA G E 2

(denominator.) The total population at risk denominator Example

includes the prevalent cases. Prevalence is often reported
If the disease under study is ovarian cancer, which
as a percentage.
obviously only affects women, the denominator should
Prevalence = Prevalent cases / Total population consist only of women in the population who, at the
Depending on the type of prevalence being calculated, the start of study observation, do not have ovarian cancer
denominator can be either an average of the population and are capable of developing ovarian cancer.
over time or a single measurement at a specific point of
time.
Risk = Incident cases / Population at-risk
Prevalence can either be calculated as a point prevalence
Risks are often reported as a scaled value, such as cases
or period prevalence. A point prevalence is calculated with
per 1,000; 10,000; or 100,000 population.
data from one specific point in time, while a period
prevalence is calculated over a range of time. Rate

Prevalence is directly affected by the incidence and Rate is another measure of health outcome occurrence
duration of the health outcome under study, which makes calculated with incident cases of the health outcome.
it a poor choice for diseases or outcomes with a short However, the denominator for a rate is the total amount of
duration or high mortality rate. person-time at-risk. Person-time is an estimate of the
actual time-at-risk in years, months, or days that all
Example
participants contributed to a study. In its simplest form,
For example, Vibrio vulnificus a disease caused by person-time is a sum of each study participants time at
consumption of raw shellfish has a low incidence and risk before experiencing the outcome of interest or exiting
short duration. Therefore, the few new (incident) cases the study. This is a better estimate of the true at-risk
that arise will remain prevalent in the population for only population because it excludes time for participants who
a short time before the cases recover or die. However, are no longer eligible to experience the outcome of
for a disease like diabetes, which has a higher risk or interest. Thus, rates are a better reflection of health
rate and longer duration, the prevalence will be higher outcome occurrence in a dynamic population, where
than the risk or rate and is a valuable measure of the participants may exit the study or become no longer at-
burden of disease in the population. risk.

Prevalence = Rate x Duration

Rate = Incident cases / Total person-time at-risk
Risk

Like prevalence, risk is also a measure of the extent of a

The unit for a rate is cases per person-time. Rates are
health outcome in a population. However, unlike
often reported as a scaled value with a time unit relevant
prevalence, risk is the proportion of an at-risk population
for the study, such as cases per 1,000 person-years,
that develops a specific health outcome within a specified
12,000 person-months, or 365,000 person-days.
amount of time. The numerator for risk is incident cases,
and the denominator includes only those at-risk of Rates are favored if the rapidity with which new cases of
developing the outcome of interest at the beginning of the health outcome or new events are occurring in the
study follow-up. population is of interest.

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 ERIC NOTEBOOK PA G E 3

Comparing Measures of Occurrence 2) Now researchers want to study the risk of head injuries
that occur while a person was riding a bicycle, in the
United States between 2000-2013. How would the risk
denominator ideally be calculated? Choose the one best
answer.
a) All people living in the United States in the time period
2000-2013
b) All people who rode a bicycle in the United States in
the time period 2000-2013
c) All people who owned or had access to a bicycle in
the United States in the time period 2000-2013
d) The actual number of documented head injuries due
to bicycle accidents in the United States in the time
period 2000-2013
e) All people who had a head injury in the United States
in the time period 2000-2013

The image of the bathtub below graphically represents the Terminology

relationships between prevalence, risk, and rate.
Prevalent cases all individuals living with the health
In this analogy, prevalence is the proportion of the tub (the outcome of interest within a specified timeframe,
total population) filled with any water (prevalent cases and regardless of when that person was diagnosed or
incident cases). Risk is the proportion of the tub filled with developed the health outcome
new, flowing water (incident cases). Rate is a measure of
Incident cases all individuals who change in status
how quickly the water flows into the tub. Prevalent cases
from one state of health to another (such as non-
only leave the prevalence pool by either recovery, death,
disease to disease) over a specific period of time
migration out of the population or loss of study follow-up
via the bathtub drain. Prevalence the proportion of a population living with a
specific health outcome within a specified timeframe
Practice Questions
Risk the proportion of an at-risk population that
Answers are located at the end of this notebook.
develops a specific health outcome within a specified
1) If researchers were studying the risk of a woman amount of time
having a baby born preterm in the United States in 2013,
Rate the frequency of incident cases per unit of
what would the at-risk population be? Assume for this
person-time
question that a pre-term birth is any birth before 39 weeks
gestation. Choose the one best answer.
a) All women in the United States in 2013 References
b) All pregnant women in the United States in 2013
c) The actual number of babies born preterm in the Dr. Carl M. Shy, Epidemiology 160/600 Introduction to
United States in 2013 Epidemiology for Public Health course lectures, 1994-
d) All babies born in the United States in 2013
2001, The University of North Carolina at Chapel Hill,
e) All pregnant women in the United States whose due
dates would mean that the baby could potentially be Department of Epidemiology
born pre-term in the year 2013

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 ERIC NOTEBOOK PA G E 4

Rothman KJ, Greenland S. Modern Epidemiology. Second 2013. Answer choice c (The actual number of babies born
Edition. Philadelphia: Lippincott Williams and Wilkins, preterm in the United States in 2013) is incorrect because
1998. this is not the at-risk population needed for a risk
measure since this is a count of babies already born
The University of North Carolina at Chapel Hill, Department
of Epidemiology Courses: Epidemiology 710, preterm. Similarly, answer choice d (All babies born in the
Fundamentals of Epidemiology course lectures, 2009- United States in 2013) is incorrect because it does not
2013, and Epidemiology 718, Epidemiologic Analysis of represent the at-risk population that would need to be
Binary Data course lectures, 2009-2013. followed over time.

Acknowledgement 2. The best answer was b: All people who rode a bicycle in
The authors of the Second Edition of the ERIC Notebook the United States in 2013. In your risk denominator, you
would like to acknowledge the authors of t he want to only include people actually at-risk of the
ERIC N ot ebook, First Edition: Michel Ib rahim , outcome. In order to have a head injury that arises from
MD, PhD, Lorraine Alexander, DrPH, Carl Shy,
MD, DrPH, and Sherry Farr, GRA, Departm ent of riding a bicycle, a person would actually have to be riding
Epidem iology at t he Univers it y of N ort h Carolina a bicycle, otherwise they would never be at-risk for the
at Chapel Hill. The First Edition of the ERIC outcome under study.
N ot eb ook was produced b y t he Educat ional Arm
of the Epidem iologic Res earch and Inform at ion Answer a (All people living in the United States in the time
Cent er at Durham, N C. The funding for the ERIC period 2000-2013) is not the best choice because all of
N ot eb ook First Edit ion was provided b y t he
Departm ent of V et erans Affairs (DV A), V et erans these people did not ride a bicycle. Answer c (All people
Healt h Adm inist rat ion (V HA), Cooperat ive who owned or had access to a bicycle in the United States
St udies Program (CSP) to prom ot e the s t rat egic in the time period 2000-2013) is incorrect for the same
growt h of the epidemiologic capacit y of t he
reason. Just because someone has access to a bicycle
DV A.
does not mean they actually rode one. Answer d (The
actual number of documented head injuries due to bicycle
Answers to Practice Questions accidents in the United States in the time period 2000-
1. The best answer was e: All pregnant women in the 2013) is not correct because the researchers are studying
United States whose pregnancy due date would mean that incident cases among all people at risk for the outcome.
the baby could potentially be born pre-term in the year The group at-risk is all people who rode a bicycle and not
2013. Since the researchers are studying risk, they need just those who actually had a head injury. Answer e (All
to measure incident cases. The denominator must include people who had a head injury in the United States in the
only those at-risk of having the outcome of interest during time period 2000-2013) is incorrect because the
the defined time-period of interest (the year 2013). researchers were not studying head injuries in general,
they were studying head injuries arising from riding a
Answer choice a (All women in the United States in 2013)
bicycle specifically.
is not the best choice because only pregnant womenand
not all women in generalare at-risk of having a preterm
baby born. Answer choice b (All pregnant women in the
United States in 2013) is a good choice but is not the best
answer choice among those listed. This is because a
women who is pregnant in 2012 may be at-risk of giving
birth to a pre-term baby is the calendar year 2013. So the
researchers would not want to limit their at-risk population
just to women who are pregnant in the United States in

ERIC at the UNC CH Department of Epidemiology Medical Center