Incidence and Prevalence PDF

Incidence and prevalence are terms commonly used in describing disease epidemiology.
Incidence
Incidence is the rate of new (or newly diagnosed) cases of the disease. It is generally reported
as the number of new cases occurring within a period of time (e.g., per month, per year). It is
more meaningful when the incidence rate is reported as a fraction of the population at risk of
developing the disease (e.g., per 100,000 or per million population). Obviously, the accuracy
of incidence data depends upon the accuracy of diagnosis and reporting of the disease. In some
cases (including ESRD) it may be more appropriate to report the rate of treatment of new cases
since these are known, whereas the actual incidence of untreated cases is not.
Incidence rates can be further categorized according to different subsets of the population –
e.g., by gender, by racial origin, by age group or by diagnostic category.
Prevalence
Prevalence is the actual number of cases alive, with the disease either during a period of time
(period prevalence) or at a particular date in time (point prevalence). Period prevalence
provides the better measure of the disease load since it includes all new cases and all deaths
between two dates, whereas point prevalence only counts those alive on a particular date.
Prevalence is also most meaningfully reported as the number of cases as a fraction of the total
population at risk and can be further categorized according to different subsets of the
population.
Point prevalence is the number of persons with disease in a time interval (eg, one year) divided
by number of persons in the population; that is, prevalence at the beginning of an interval plus
any incident cases.
The distinction between point prevalence and period prevalence is often not made because
most prevalence estimates that you will encounter in the medical literature are point prevalence.
Period prevalence is the proportion of a population that has the characteristic at any point
during a given time period of interest. “Past 12 months” is a commonly used period.
Lifetime prevalence is the proportion of a population who, at some point in life has ever had
the characteristic.
Incidence to Prevalence
The relationship between incidence and prevalence depends greatly on the natural history of
the disease state being reported. In the case of an influenza epidemic, the incidence may be
high but not contribute to much growth of prevalence because of the high, spontaneous rate of
disease resolution. In the case of a disease that has a low (or zero) cure rate, but where
maintenance treatment permits sustained survival, then incidence contributes to continuous
growth of prevalence. In such cases, the limitation on prevalence growth is the mortality which
occurs in the population. Obviously, prevalence will continue to grow until mortality equals or
exceeds the incidence rate.
An example of this relationship is shown below. The disease incidence is 100 per year.
Mortality rate is 20% per year. As seen, prevalence grows until the death rate equals the
incidence.
Another feature of the prevalence growth that should be noted is that during the earlier years
the growth of prevalence is very fast, but slows towards zero growth after 15 years.
Absolute Risk The incidence of a disease in a population is termed absolute risk. Can
indicate the magnitude of risk in a group of people with a certain exposure, but: It does not
take into consideration the risk of disease in the nonexposed individuals, it does not indicate
whether the exposure is associated with an increased risk of disease. Absolute risk do not
stipulate an explicit comparison.
Absolute risk is always written as a percentage. It is the ratio of people who have a medical
event compared to all of the people who could have an event.
For example, if 26 out of 100 people will get dementia in their lifetime, the absolute risk is
26/100 or 26%.
The higher the denominator (the bottom number), the lower the absolute risk. For example, a
person who has a 1/100 chance (1%) of getting a disease has a higher chance than someone
with a 1/1000 (0.1%) chance.
Absolute risk reduction (also called risk difference) is the absolute difference in outcomes
between one group (usually the control group) and the group receiving treatment.
Absolute Risk Reduction (AAR) = CER (Control Event Rate) – EER (Experimental Event
Rate)
Example : 25 percent of people of depression medication have poor outcomes, but 8 percent
of people who receive medication and counselling report bad outcomes. The absolute risk
reduction is 25% – 8% = 13%. So if 100 people were treated with both medication and
counselling, 8 would report poor outcomes.
Example 2: Let’s say you had the following data:
YES NO
Exposed 8 992
Not Exposed 11 989

8 out of a total of 1000 “Exposed” patients is 0.008. This is the Experimental Event Rate.
11 out of a total of 1000 “Not Exposed” patients is 0.011. This is the Control Event Rate.
The absolute risk reduction is: CER-EER = 0.011-0.008 = 0.003.
Risk ratio
Definition of risk ratio
A risk ratio (RR), also called relative risk, compares the risk of a health event (disease, injury,
risk factor, or death) among one group with the risk among another group. It does so by dividing
the risk (incidence proportion, attack rate) in group 1 by the risk (incidence proportion, attack
rate) in group 2. The two groups are typically differentiated by such demographic factors as
sex (e.g., males versus females) or by exposure to a suspected risk factor (e.g., did or did not
eat potato salad). Often, the group of primary interest is labeled the exposed group, and the
comparison group is labeled the unexposed group.
Method for Calculating risk ratio
The formula for risk ratio (RR) is:
Risk of disease (incidence proportion, attack rate) in group of primary

interest
Risk of disease (incidence proportion, attack rate) in comparison group

• A risk ratio of 1.0 indicates identical risk among the two groups.
• A risk ratio greater than 1.0 indicates an increased risk for the group in the numerator,
usually the exposed group.
• A risk ratio less than 1.0 indicates a decreased risk for the exposed group, indicating
that perhaps exposure actually protects against disease occurrence.
EXAMPLES: Calculating Risk Ratios
Example A: In an outbreak of tuberculosis among prison inmates in South Carolina in 1999,

28 of 157 inmates residing on the East wing of the dormitory developed tuberculosis, compared
with 4 of 137 inmates residing on the West wing. These data are summarized in the two-by-
two table so called because it has two rows for the exposure and two columns for the outcome.
Here is the general format and notation.
Table 3.12A General Format and Notation for a Two-by-Two Table

Ill Well Total
Total a + c = V1 b + d = V0 T
Exposed a b a + b = H1
Unexposed c d c + d = H0
In this example, the exposure is the dormitory wing and the outcome is tuberculosis) illustrated
in Table 3.12B. Calculate the risk ratio.
Table 3.12B Incidence of Mycobacterium Tuberculosis Infection Among Congregated,

HIV-Infected Prison Inmates by Dormitory Wing — South Carolina, 1999
Developed tuberculosis?
Yes No Total
Total 32 262 T = 294
East wing a = 28 b = 129 H1 = 157
West wing c=4 d = 133 H0 = 137
Data Source: McLaughlin SI, Spradling P, Drociuk D, Ridzon R, Pozsik CJ, Onorato I.
Extensive transmission of Mycobacterium tuberculosis among congregated, HIV-infected
prison inmates in South Carolina, United States. Int J Tuberc Lung Dis 2003;7:665–672.
To calculate the risk ratio, first calculate the risk or attack rate for each group. Here are the
formulas:
Attack Rate (Risk)

Attack rate for exposed = a ⁄ a+b
Attack rate for unexposed = c ⁄ c+d
For this example:
Risk of tuberculosis among East wing residents = 28 ⁄ 157 = 0.178 = 17.8%

Risk of tuberculosis among West wing residents = 4 ⁄ 137 = 0.029 = 2.9%
The risk ratio is simply the ratio of these two risks:
Risk ratio = 17.8 ⁄ 2.9 = 6.1
Thus, inmates who resided in the East wing of the dormitory were 6.1 times as likely to develop
tuberculosis as those who resided in the West wing.
RR calculation with confidence interval
Attributable risk (AR)

Attributable risk (AR) or risk difference is the difference between the incidence rates in
exposed and non-exposed groups. In a cohort study, AR is calculated as the difference in
cumulative incidences (risk difference) or incidence densities (rate difference). This reflects
the absolute risk of the exposure or the excess risk of the outcome (e.g. disease) in the exposed
group compared with the non-exposed group. AR is sometimes referred to as attributable risk
in the exposed because it is used to quantify risk in the exposed group that is attributable to the
exposure.
Population attributable risk (PAR)
Population attributable risk (PAR) is the proportion of the incidence of a disease in the
population (exposed and unexposed) that is due to exposure. It is the incidence of a disease
in the population that would be eliminated if exposure were eliminated.
The PAR is calculated by subtracting the incidence in the unexposed from the incidence in
the total population (exposed and unexposed).
PAR is usually expressed as a percentage. The PAR% is calculated by dividing the
population attributable risk (PAR) by the incidence in the total population and then
multiplying the product by 100 to obtain a percentage.
PAR measures the potential impact of control measures in a population, and is relevant to
decisions in public health.
In order to calculate PAR, the prevalence of exposure in the study population must be
known or estimated (PAR = AR × prevalence of exposure to risk factor in the population).

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Incidence and prevalence are terms commonly used in describing disease epidemiology.

Not Exposed 11 989

The absolute risk reduction is: CER-EER = 0.011-0.008 = 0.003.

Definition of risk ratio

Method for Calculating risk ratio

The formula for risk ratio (RR) is:

Risk of disease (incidence proportion, attack rate) in group of primary

Risk of disease (incidence proportion, attack rate) in comparison group

EXAMPLES: Calculating Risk Ratios

Example A: In an outbreak of tuberculosis among prison inmates in South Carolina in 1999,

Table 3.12A General Format and Notation for a Two-by-Two Table

Table 3.12B Incidence of Mycobacterium Tuberculosis Infection Among Congregated,

Attack Rate (Risk)

For this example:

Risk of tuberculosis among East wing residents = 28 ⁄ 157 = 0.178 = 17.8%

The risk ratio is simply the ratio of these two risks:

Risk ratio = 17.8 ⁄ 2.9 = 6.1

RR calculation with confidence interval

Attributable risk (AR)

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