Equency Measures Used in Epidemiology
Equency Measures Used in Epidemiology
Equency Measures Used in Epidemiology
Epidemiology
Alick Mwambungu
[email protected]
Session 6
AM
Introduction to Frequency
measures
• In epidemiology, many nominal variables
have only two possible categories: alive or
dead; case or control; exposed or
unexposed etc.
• Such variables are called dichotomous
variables.
• The frequency measures used with
dichotomous variables are
ratios,proportios,and rates.
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Rates, Ratios and Proportions
• Three general classes of mathematical
parameters.
• Often used to relate the number of cases
of a disease or health outcome to the size
of the source population in which they
occurred.
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Vocabulary
• Ratio (a/b) the generic term
• Proportion (a/a+b ) Numerator is included in the
denominator
Range 0-1.0,Time may be specified ,but is not
necessary.
• Rate (∆Y/∆X) – A measure of change in one
quantity per unit change in another
• Risk- Probability that an event will occur
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Ratio
• Used to compare two quantities
1:1.1 ratio of female to male births
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Ratio
• Obtained by dividing one quantity by
another. These quantities may be related
or may be totally independent.
• Usually expressed as : X/Y x 10n
• Example: Number of still births per
thousand live births
#stillbirths x 1000
#live births
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proportion
• A specific type of ratio in which the
numerator is included in the denominator,
usually presented as a percentage
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Calculation of proportion:
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Rate
• A measure of how quickly something of
interest happens.
• It measures the occurrence of an event in
a population over time.
• The basic formula for a rate is as follows:
Rate= number of cases or events occurring during a given time period x 10ᶰ
population at risk during the same time period
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• As can be seen from the above
discussions ,ratios, proportions and rates
are not three distinctly different kinds of
frequency measures.
• They are all ratios: proportions are a
particular type ratio, and some rates are a
particular type of proportion.
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• When we call a measure a ratio, we
usually mean a non-proportional ratio
• when a measure is called a proportion,
usually it means a proportional ratio that
doesn’t measure an event over time
• When the term rate is used it usually
means a proportional ratio that does
measure an event in a population over
time.
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Uses of Ratios, Proportions and
Rates
• In public health, ratios and Proportions are
used to characterize populations by
age,sex,race,exposure and other
variables.
• Ratios, proportions and most important
rates are used to describe the three
aspects of the human condition:
• Morbidity(Disease),mortality(Death) and
Natality(Birth)
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Morbidity Frequency measures
• To describe the presence of disease in a
population,or the probability(risk) of its
occurrence-morbidity frequency measures
are used.
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Measures of disease frequency
• Incidence (I): Measures new cases of a disease
that develop over a period of time.
• Prevalence (P):Measures existing cases of a
disease at a particular point in time or over a
period of time.
• Prevalence can be viewed as describing a pool
of disease in a population.
• Incidence describes the input flow of new cases
into the pool.
• Fatality and recovery reflects the output flow
from the pool.
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Prevalence versus Incidence
Prevalence Incidence
• Existing cases New cases
• Measures how much Measures changes in
disease is in the pop disease occurrence
• Used for description, Used for investigating
planning health care the causes of disease
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Incidence
• Incidence quantifies the number of new events
or cases of disease that develop in a population
of individuals at risk during a specified time
interval.
• There are two specific types of incidence
measures, cumulative incidence and incidence
rate or density.
• Cumulative incidence(CI) is the proportion of
people who become diseased during a specified
period of time and is calculated as:
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CI= number of new cases of a disease during a given period of time
total population at risk
• Cumulative incidence provides an estimate of the probability ,or risk,
that an individual will develop a disease during a specified period of
time.
• For example, in a study of oral contraceptive(OC) and bacteriuria a
total of 2390 women aged 16 to 49 years were identified who were
free from bacteriuria.Of these ,482 were OC users at the initial
survey in 1973.At the second survey in 1976 ,27 of the OC users
had developed bacteriuria .
• This results in a cumulative incidence of bacteriuria among OC
users of 27 per 482 or 5.6% during this 3 –year period.
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Cumulative incidence
• A cumulative incidence of bacteriuria of 5.6%
among OC users would be viewed very
differently if it referred to a 6-month period, a 3-
yr period or a 10-yr period.
• The cumulative incidence assumes that the
entire population at risk at the beginning of the
study period has been followed for the specified
time interval for the development of the outcome
under investigation.
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• Even if all subjects enter the study at the same time,
some may become lost during the follow-up ,or the time
during which the outcome could be observed ,will not be
uniform for all participants.
• To account for these varying time periods of follow-up
,one approach would be to restrict the calculation of the
incidence to a period of time during which the entire
population provided the information.
• This would, however necessitate disregarding the
additional follow-up information available for some of the
population.
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Cumulative incidence
• Most common way to estimate risk
• Always a proportion
• Assumes a fixed cohort
• For brief specified periods of time e.g. an
outbreak
• Formula does not reflect continually changing
population size for dynamic cohorts
- Does not allow subjects to be followed for
different time periods.
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Incidence Rate or Density
• A more precise estimate of the impact of
exposure in a population that utilizes all
available information is called the
incidence rate(IR) or Incidence density.
• This is considered to be a measure of the
instantaneous rate of development of
disease in a population and is defined as:
ID= number of new cases of a disease during given time period
total person-time of observation
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Incidence Rate or Density
• As with any measure of incidence, the
numerator of the incidence density is the
number of new cases in the population.
• The denominator, however is now the sum of
each individual’s time at risk or the sum of the
time that each person remained under
observation and free from disease.
• In presenting an incidence rate, it is essential to
specify the relevant time units-that is-person-
day,person-month,person-year,etc
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Incidence Rate or Density
• Figure 4-1 page 59(Epidemiology in Medicine) illustrates
the calculation of person-time units, based on the
experience of a hypothetical group of five subjects, two
of whom developed the disease of interest during a 5-yr
follow-up period.
• The cumulative incidence of disease could thus be
calculated as 2 cases per 5 individuals over a 5-year
period
• This measure of development of disease would be
misleading ,since it does not reflect the fact that only one
of the five subjects(Subject C) was infact observed for
the entire follow-up period.
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• Subject A was observed for only 2 years before
being lost to follow-up., while subjects B,D and E
were followed for 3.0,4.0 and 2.5
yrs,respectively.
• The total time at risk for this population of five
subjects, could be obtained by adding their
individual times-16.5 person-years.
• The incidence density(ID) would be calculated
as follows:
• ID=2 cases/16.5 person-years
=12.2/100 person-years of observation
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Prevalence
• Measures existing cases of a health condition
• Primary feature of a cross-sectional study
• Two types of Prevalence:
-Point Prevalence
-Period Prevalence
• Prevalence quantifies the proportion of individuals in a
population who have the disease at a specified instant
and provides an estimate of the probability(risk),that an
individual will be ill at a point in time.
• The formula for calculating the prevalence(P) is:
P= Number of existing cases of a disease
total population
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Prevalence
• For example, in a visual examination survey
conducted in Massachusetts among individuals
52 to 85years of age,310 of the 2477 persons
examined had cataracts at the time of the
survey.
• The prevalence of cataract in that age group
was therefore 310 per 2477,or 12.5%.
• Thus prevalence can be thought of as the status
of the disease in the population at a point in time
and as such is also referred to as point
prevalence.
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Point Vs. period prevalence
• The amount of disease present in a
population is constantly changing.
• Sometimes, there is need to know how
much of a particular disease is present in
a population at a single point in time-to get
a kind of ‘’stop action’’ or ‘snap shot’ look
at the population with regard to that
disease.
• Point prevalence is used for that purpose.
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• Point prevalence is not an incident rate, because the
numerator includes pre-existing cases.
• It is a proportion because the persons in the numerator
are also included in the denominator.
• At other times we want to know how much of a particular
disease is present in a population over a longer period.
• Period prevalence is used in this case. The numerator
in period prevalence is the number of persons who had a
particular disease or attribute at any time during a
particular interval.
• The interval can be a week,month,year etc.
AM
• Example:
• In a survey of patients at an STD
clinic,180 of 300 patients interviewed
reported use of a condom at least once
during the 2 months before the interview.
• The period prevalence of condom use
over the last 2 months is:
• 180/300x 100 = 60%
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Comparison of prevalence and
incidence
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 at
the second survey and incidence.
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1.Prevalence at the second survey
X=antibody positive=35
Y=population=5,000
x/y x 10ᶰ=35/5000x1000
=7 per 1,000
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• Incidence during the 12-month period:
• X=number of new positives during the 12-
month period=35-25=10
• Y=population at risk=5,000-25=4,975
• x/y x10ⁿ=10/4,975 x1,000=2 per 1,000
• High prevalence of a disease within a
population may reflect high risk, or it may
reflect prolonged survival without cure.
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• Conversely, low prevalence may indicate
low incidence, a rapidly fatal process, or
rapid recovery.
• Prevalence is often used rather than
incidence to measure the occurrence of
chronic diseases such as osteoarthritis
which have long duration and dates of
onset which difficult to pinpoint.
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Interrelationship between incidence
and prevalence
• The proportion of the population that has a
disease at a point in time (prevalence) and the
rate of occurrence of new disease during a
period of time(Incidence) are closely related.
• Prevalence depends on both the incidence rate
and the duration of the disease from onset to
termination.
• If the incidence of a disease is low but those
affected have the condition for a long period of
time, the prevalence will be high relative to the
incidence rate.
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• If the incidence rate is high but the duration is
short ,either through prompt recovery or death,
the prevalence will be low relative to the
incidence.
• This interrelationship between incidence and
prevalence can be expressed mathematically by
saying that the prevalence(P) is proportional to
the product of the Incidence rate(I) and the
average duration of the disease(D).
P=I x D
When two of the measures are known, the third
can be calculated by substitution.
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• Example:
Average annual incidence rate of lung
cancer in Connecticut between 1973 to
1977 was 45.9 per 100,000.and the
average annual prevalence was 23.0 per
100,000.Calculate the average duration
of lung cancer?
D=P/I =23.0/105 =0.5 year.
45.9/
105/year
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House Guest Example
P=IXD
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Mortality Frequency Measures
• A mortality rate is a measure of the frequency of
occurrence of death in a defined population.
Mortality rate =deaths occurring during a given time period x 10ⁿ
# of the population among which deaths occurred
• Crude mortality rate is the mortality rate from all causes of death
for a population.
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Age-specific mortality rate
• This is the mortality rate limited to a
particular age group. The numerator is the
number of deaths in that age groups; the
denominator is the number of persons in
that age group in the population.
• Some specific types of age-specific
mortality rates are
neonatal,postneonatal,and infant mortality
rates.
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Mortality Rates
• Infant mortality rate: Death under one year of age during a given
time interval divided by number of live births reported during the
same time interval.
• These are most commonly used rates for measuring the risk of
dying during the first year of life. These rates are some of the most
frequently used measures for comparing health services among
nations.
• Neonatal mortality rates: Are an index of the risk of dying in the
first 28 days of life. The numerator is the number of deaths in one
year for children younger than 28 days of age. The denominator is
the number of live births in the same year.
• Post neonatal mortality rate: This is an index of the risk of death in
infants aged 28 days to 11months during a given time interval
divided by live births during the same time interval.
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Death-to-case ratio
• Is the number of deaths attributed to a
particular disease during a specified time
period divided by the number of new cases of
that disease identified during the same time
period
• Death-to-case ratio=no.of deaths of particular disease during specified period.
No of new cases of the disease identified during same period.
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Case-fatality rate
• The Case-Fatality rate is the proportion of persons who
die from a particular condition (Cases). The formula is:
Deaths from a specific disease x 10ⁿ
Cases of that disease
• Unlike the death-to-case ratio, which is simply the ratio
of cause- specific deaths to cases during a specified
time, the case-fatality rate is a proportion and requires
that the deaths in the numerator be limited to the cases
in the denominator.
• Thus, if 11 newborns were to develop listeriosis and two
of these newborns died as a result, the case-fatality rate
would be
2deaths/11 cases =18.2%
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Proportional Mortality Rates
• Defined as the number of deaths assigned to a
specific cause in a calendar year, divided by the
total number of deaths in that year, the quotient
multiplied by 100
• Example:
Country X - total deaths from all causes in 1970:
1,500,000; deaths from cancer: 675,000
Proportional mortality ratio= 675,000/1,500,000 x 100
= 45% of total deaths per year from cancer
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Standardized Mortality Ratios
• One problem that arises in comparing crude rates of
disease between populations is that the groups may
differ with respect to certain underlying characteristics
,such as age,sex,or race that may affect the overall rate
of disease.
• For example, the crude mortality rate from cancer in the
US in 1940 was 120 per 100,000,as compared with 183
per 100,000 in 1980.
• These crude rates ,indicating an overall 53-percent
increase in cancer mortality during this 40 –year period,
have erroneously suggested a trend so alarming as to be
considered indicative of an epidemic of cancer
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Standardisation and the SMR
• Age and sex specific rates can be compared between
times, places and sub-populations
• Age and sex specific rates may be imprecise in small
studies
• Age and sex specific tables are usually large and difficult
to assimilate
• If so, you may calculate the summary, overall (crude)
rate
• Overall actual rates (crude) rates may mislead
• Age and sex structure of the compared population
probably differs
• If so, age and sex are confounding variables
• Therefore, we need to adjust (or standardise) the rates
for age, sex or both
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Standardized Mortality ratios
• The standardized mortality ratio or SMR is the ratio of
observed deaths to expected deaths according to a specific in a
population and serves as an indirect means of adjusting a rate.
• The figure for expected deaths reflects the number of deaths for
the larger population from which the study sample has been
taken.
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Standardized Mortality Ratios
• An SMR is essentially a comparison of the number of the
observed deaths in a population with the number of
expected deaths if the age-specific death rates were the
same as a standard population. It is expressed as a ratio
of observed to expected deaths, multiplied by 100.
• SMRs equal to 100 imply that the mortality rate is the
same as the standard mortality rate. A number higher
than 100 implies an excess mortality rate whereas a
number below 100 implies below average mortality.
• An SMR is calculated as the number of deaths observed
within an area divided by the expected number of deaths
within that area. This ratio is then multiplied by 100.
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• The calculation used to determine the
SMR is simply: number of observed
deaths/number of expected deaths.
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Standardized Mortality Ratio
• To arrive at the expected number of
deaths, for each age group, the standard
age-specific death rate is multiplied by the
local population in that age group.
• The number of expected deaths in each
age group are then summed across all
ages to arrive at the expected number of
deaths for the local population.
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• See attached sheet form calculations.
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