UNIT 4

MEASUREMENT IN
EPIDEMIOLOGY

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 Epidemiology is a quantitative Science
applied to describe groups of persons
 The ability for any epidemiological investigation is the ability
to quantify the occurrence of disease

Measurement of disease occurrence:
• Prevalence
• Incidence
 Measurement of associations of disease occurrence:
 Rate
 Ratio
 Proportion

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MEASURMENT OF DISEASE OCCURANCE:
• Number of cases in a given community can give more

sense if they are related to the size of the population

Population size can be determined by calculating
• Ratios
• Proportions
• Rates
They are usefull to provide :
• Information about probability of occurrence of health

events
• Population at high risk of acquiring the disease.
• In designing appropriate Public Health Intervention

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Raw numbers (counts):
 The simplest and most performed quantitative
measurement in Epidemiology
 The number of persons in the group studded who have
particular disease or particular characteristic
E.g. number of student
 Used to:
 Monitor occurrence of infectious diseases
 Draw an epidemiologic curve
 Develop plan

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Ratio:
 Expresses relation ship between two items in the
form of X:Y
 Compares relative frequency of occurrence of
some event to the other event
 E.g. The female to male ratio of a disease in the
school
Proportion:
 It is a type of ratio (expressed as a percent) in
which X is included in Y
 Numerator is included in the denominator.
E.g male/both sexes (proportion of male in
community)
Percentage
 (number per hundred) is one of the most common
ways of expressing proportions

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Number per 1000 or per 100,000 and per
1,000,000, or any other convenient base
may also be used
Rate: Measures the occurrence of an event in
a population over time
 It can be seen as a proportion with a time
dimension
 It measures the occurrence of deaths
(mortality), births ( natality)
 Rates are often proportions

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Rates must:
 Include persons in the denominator who reflect
the population from which the cases in
numerator arose
 Include counts in the numerator which are for
the same time period as those from the
denominator
 Includes only persons in the denominator who
are " at risk" for the event

 E.g. measles cases in under five in 2005

Under five children in 2005
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 Common measures of disease frequency:
 Measurement of disease is more difficult than that of
death because:
 Sickness may not be easily recognizable.
 Sickness may occur repeatedly in one person.
 Person may suffer from many diseases at one time.
 The frequency of health related events are measured
by Risk, Prevalence and Incidence rate.
 Risk (cumulative incidence): the likely hood that a
person will contract a disease.
 Group of people who have potential of getting disease
Risk = New cases occurred during a given time period
Population at risk during the same period

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Measurements of morbidity

Morbidity rates are rates used to

quantify the occurrence of disease.
Measures of morbidity include
1.Incidence
2.Prevalence

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Incidence:
 The number of new cases or events occurring in a
defined population with in a given period of time.
 It is the best indicator of whether a condition is
decreasing, increasing or remaining static.
Incidence rate: is a rate which measures the occurrence of
new cases of disease in the defined population during a
specified period of time
 Incidence rate = No of new cases at observation period
person during the same time observat.

Ex-In sene 2000 there were 50 new cases for relapsing

fever in kebele x total population was 5000
Incidence rate = 50/5000 * 1000= 10 new case per 1000
population

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 Incidence

The critical element in the definition of

incidence is new cases of disease, then
population at risk.
Because incidence is a measure of new
events (i.e. transition from a non-diseased to
a diseased state), incidence is a measure of
risk.

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 Incidence

For incidence to be a measure of risk we

must specify a period of time and we must
know that all of the individuals in the group
represented by the denominator have been
followed up for that entire period.

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 Incidence

The choice of time period is arbitrary:

We could calculate incidence rate in one
week, one month, one year, 5 years, and
so on.
Incidence rates can be used to make
statements about the risk of disease.

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 Special Types of Incidence: Attack Rate
Narrowly defined population
Observed for a limited time (e.g. epidemic).
oUsually expressed as a percent.

(primary) Attack rate =

Number of new cases among the
population during the period x 100
Population at risk at the
beginning of the period

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Attack Rate: Example
Of 75 persons who attended a church picnic, 46
subsequently developed gastroenteritis.
a) Calculate the attack rate of gastroenteritis :
x = Cases of gastroenteritis occurring within the
incubation period for gastroenteritis among
persons who attended the picnic = 46
y = Number of persons at the picnic = 75
AR= 46/75 x 100%

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 Incidence measures rapidity with which
newly diagnosed patients develop over time.
 Most common way of measuring and
comparing the frequency of disease in
populations.
Uses of Incidence
For etiologic studies of both acute and
chronic diseases.
Direct indicator of risk
Helps to test hypothesis

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Prevalence:
The amount of disease that is already present in a
population
Prevalence Rate
= all new & pre-existed case at given time period X
Population during the same time period
It is the total number of newly occurring plus pre
existing cases in a given population with in a
specified period of time.

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Prevalence =Incidence + Duration

I = New
Key
P=Prevalence
P = All I= Incidence
D= Death
R= Recovery
D R

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Prevalence Rate
Incidence Rate
 No specification in
time of on set is  There is limited time
required  Denominator always includes
 Denominator always population at risk
include the whole
population
 I D= P
 I  in acute diseases
 P= Incidence +
Duration  Counts only new cases
 P in chronic diseases
 P in acute disease
P ~ I+D
If P = I+D

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Prevalence Uses
 To determine work load
 Planning of health care services &

human resources
 For monitoring of diseases control

and prevention programs

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Types of prevalence
◦ Point prevalence
◦ Periodic prevalence
Point prevalence: Measures proportion of a
population with a certain condition at a given point
in time
Point prevalence rate = Existing cases at one point in time x K
Total population
 e.g., prevalence of HIV infections in Samara on
January 1, 2005.
 prevalence of depression among
widows/widowers 6 months after the death of a
spouse.

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 Prevalence question

Interview question Type of measure:

Do you currently have Point prevalence
asthma??
Have you had asthma in the Period prevalence
last 10 years??
Have you ever had asthma? Lifetime
prevalence

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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 facilities

(better reporting)
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Period prevalence:
• Measures the proportion of a population that

is affected with a certain conditions during a

specified period of time

Period prevalence = Existing cases over a period of time x K

Total Population

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COMMN MEASURES OF ASSOCIATION

A measure of comparison between:

◦ Determinants or (risk factor)  exposure
◦ Effect or occurrence of disease  out come
 E.g. Rate Ratio (relative risk, risk ratio)
and Odds Ratio, Etiologic (Attributable)
fraction

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 Relative Risk or Risk Ratio (RR)
 compares risk of some health-related events (often

disease or death) in two groups, typically in

persons exposed to the disease to those not
exposed

RR = Risk (incidence) in exposed

Risk ( Incidence) in non exposed
Risk (incidence) in exposed = A/A+B - disease rate
Risk (Incidence) in non exposed = C/C+D - disease
rate

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 TWO-BY- TWO Table Showing Associations
OR

RR

OR= A/C RR= A/A+B

B/D C/C+D

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Odds Ratio, (cross product ratio) (OR)
 It is another measure of association which

quantifies relation ship between an exposure

and health out come from a comparative study

Odds – a/c or a:c

Odds ratio = the ratio of ratio

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  Example
Non Fatal MI  OR= a/b / c/d
OC Yes No Total
= ad/bc
Yes 20 (a) 14 34  OR=20x45
(c) a+c 6x14
 900/84
No 6 (b) 45 (d) 51  10.7
b+d  Since OR is > 1 the use
Total 26 59 85 of oral contraceptive is
a risk facto for MI
a+d c+d a+b+c+d

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 Attributable Risk (AR)
The attributable risk is the difference between
disease rate in exposed persons (or in the total
population) and the rate in non-exposed: avoid
confounders

 AR =

(Risk of Exposed – Risk of non exposed)

Useful for
◦ Public health intervention
◦ Priority setting
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Population Attributable Risk (PAR)
 It reflects the excess risk in the whole

population, not in exposed group =

attribute to the study population
 PAR= R population - R un exposed

population
 It is a compound measure and

includes prevalence

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

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 Mortalityrates could be classified into
three main types:
oCrude rates
oSpecific rates
oStandardized or adjusted rates

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Crude, specific and adjusted mortality rates
Any rate can be expressed for a total population
(crude or adjusted rates) or for a population
subgroup (specific rates).
 
Crude rates: are summary rates based on the
actual number of events in the total population
over a given period of time, e.g. Crude Birth
Rate, Crude Death Rate (CDR).

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Specific rates: are rates of health events in
specific subgroups of the population (a
specific age group, sex, race, marital status,
etc) over a given period of time, e.g. Infant
Mortality Rate (IMR), Maternal Mortality
rate.
To be able to clearly understand what
differences exist between crude and specific
rates in general, the discussion will be about
CDRs and specific death rates (particularly
age specific rates). 12/20/22 41
Crude death rate gives a summary result of the
total population, while age specific rate gives
separate rate for the different age strata.
Crude death rate is not appropriate for
comparison of the risk of death in different
locations. While comparison of risk of death for
each age group is possible by age specific death
rate.
Crude death rate gives lamped information;
specific age groups at high risk of death can’t be
identified separately.
In the contrary, Age specific death rates give
detailed information. 12/20/22 42
Adjusted rates
In search of a rate which can give a summary
rate and at the same time allows interpretation
as to the risk of disease or death of a population
making comparison of different populations
possible, epidemiologists have come up with a
statistically created rate called Adjusted rate.

Adjusted rate is a rate, which overcomes the

limitations of both crude rates as well as specific
rates. Rates can be adjusted by sex, race or age,
etc but the most common adjustment is by age.
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Measures of Mortality
Measures of mortality are used to quantify the
occurrence of deaths in a defined population
during a specified period. Some of the
measures include:
How to calculate the different mortality rates
and ratios:
 a) Crude Death Rate = Total number of deaths in a year X 1000
Average (or midyear) population

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b) Age specific Mortality Rate =
No. of deaths in a specific age in a year X 1000
Average (midyear) population of the specific age group
 

c) Sex specific Mortality Rate =

No. of deaths in a specific sex in a year X 1000
Average (midyear) population of the specific sex

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Neonatal Mortality Rate
 
= No. of deaths of children less than 4 weeks old in a yr X 1000
No. of live births in same year

Infant Mortality Rate (IMR)

= No. of deaths of children less than 1 year old in a year X 1000
No. of live births in the same year

Maternal Mortality ratio (MMR)

No of deaths of women from pregrnancy related causes in yr
  100,000
No of live births in the same year

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• Some commonly used specific death rate:
• Infant Mortality Rate: the number of
deaths of infants up to the age of one year
per 1000 live-birth in a given year

IMR = NO of deaths < 1 yrs of age x 1000

No of live birth during the same period

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 Use

◦ To measure health status of the community

◦ To see availability and effective use of health
care
 E.g. Perinatal cares
• Neonatal Mortality Rate (NMR)
NMR = No death up to 28 days of age in calendar yr x1000
Number of live births in the same calendar year

 Use:To see condition of the fetus and pre and

post delivery

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Child Mortality rate (CMR)
 Number of deaths at ages of 1-4 yrs in a given area per
1000 children in that age group at the mid point of the year
concerned

CMR = No of deaths of children 1-4 yrs of age during a yr x 1000

# of children 1-4 yrs of age at the middle of the yr

 Use: Main environmental factor affecting the children:

 Nutrition
 Sanitation
 Communicable Disease of children
 Accident occurring in and around the home
 It is sensitive indicator socioeconomic development in a
community

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Under Five Mortality Rate:
 Is the number of deaths of children under five

years of age per 1000 children age under 5 years in

a calendar year
 U5MR = No of deaths U5 yrs of age in the given yr x 1000
# Of children U5 yrs of age in the middle of the yr

 This rate combines both infant and child mortality

rate

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Are you with me!!

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QUESTION

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