INTRODUCTION

Successes in treating and delaying advanced communicable and chronic disease has shifted
research attention to understanding the mechanisms underlying early subclinical disease and
its prevention. Comprehensive assessment of risk factors and sophisticated measurement of
valid surrogates of clinical disease are often now required in epidemiological research. The
1948 World Health Organization definition of health is an ideal, and historically has been
problematic to measure. For that reason, measurement has targeted ill-health rather than
health. However, newer generations of health measures, such as healthy life expectancy are
beginning to correct the large imbalance in the orientation of epidemiologic measurement.
DEFINITION
1. Epidemiology : Epidemiology as defined by John M as “the study of the distribution and
determinants of health-related states or events in specified populations, and the
application of this study to the prevention and control of health problems”
2. Measurement: Measurement is collection of quantitative data. A measurement is made
by comparing a quantity with a standard unit.
3. Variate: Any piece of information referring to the patient or his disease is called variate.
E.g.: cancer lung, blood pressure
4. Circumstance: any factor in the environment that might be suspected of causing a
disease. e.g.: air pollution
BASIC REQUIREMENTS OF MEASUREMENTS
1. Validity: The validity of a measurement tool is considered to be the degree to which the
tool measures what it is intended to measure.
2. Reliability: Reliability is the consistency of a measure. A measure is said to have a high
reliability if it produces consistent results under consistent conditions.
3. Accuracy: accuracy of a measurement system is the degree of closeness of measurements
of a quantity to that quantity's actual (true) value.
4. Sensitivity: Sensitivity (also called recall rate ) measures the proportion of actual
positives which are correctly identified as such. E.g. The percentage of sick people who
are correctly identified as having the condition.
 5. Specifity: Specificity measures the proportion of negatives which are correctly
identified. E.g. The percentage of healthy people who are correctly identified as not
having the condition.
TOOLS FOR MEASUREMENTS
A. Rate: A rate measures the occurrence of some particular event in a population during a
given time period or Frequency of events that occur in a defined time period, divided by the
average population of risk.
Rate = Numerator (Constant multiplier)
Denominator
E.g.: Death Rate: number of deaths in one year/ midyear population (1000)
The elements of rate are:
 Numerator
 Denominator
 Time specification
 Multiplier
B. Ratio: Ratio expresses a relation in size between two random quantities. The numerator is
not a component of denominator. The numerator may involve an interval of time or may be
instantaneous of time.
E.g.: Number of children with scabies at a certain time
Number of children with malnutrition at a certain time
Male and female dengue infection ratio = 70/35 or 2 males to one female (2: 1)
C. Proportion: The proportion is a ratio which indicates the relation in magnitude of a part of
the whole.
 Numerator is always included in the denominator.
 No measurement unit is present;
 The value always exist between > 0 to < 1
 Often expressed as %
E.g. from 7,999 females aged 16 – 45 y, 2,496 use modern contraceptive methods.
The proportion of those who use modern contraceptive methods = 2,496 x 100 = 31.2%
7,999
CONCEPT OF NUMERATOR AND DENOMINATOR
 Numerator: it refers to the number of times an event has occurred in a population,
during a specified time period. The numerator is a component of denominator in
calculating rate, but not in a ratio.
 Denominator: numerator has less meaning if it is not associated with denominator. The
epidemiologist selects an appropriate denominator from:
Related to population:
1. Midyear population: It refers to the population estimated as on first of July of an year
2. Population at risk: The term is applied to all those to whom an event could have
happened whether it did or not. E.g.: general fertility rate
3. Person time: In cohort studies persons may enter the study at different times.
Consequently they are at observation for varying time periods. In such cases the
denominator is a combination of both persons and time and it commonly occurs as
person-years. E.g.: if 10 persons remain for 10 years in a study, it is considered as 100
person- years of observation.
4. Person – distance: A variant of person time is person distance. e.g.: passenger miles.
5. Sub groups of population: The denominator may be subgroups of population like age,
sex occupation etc…
Related to total events: The total events are considered as denominator instead of total
population.
E.g.: the number of accidents per 1000 vehicles will be more useful as many are not using
vehicles.
PURPOSES OF HEALTH-RELATED MEASUREMENTS
The main purposes are:
1. Disease and Injury Prevention.
2. Health Promotion.
3. Health Services Planning and Intervention Design.
4. Evaluation.
TYPES OF EPIDEMIOLOGIC MEASURES
A. Measures of disease frequency
B. Measures of association
C. Measures of potential impact
A. MEASURES OF DISEASE FREQUENCY
i. Measurement of mortality
Data source: Death Certificate
Limitations of mortality data:
 The incomplete reporting of deaths
 Lack of accuracy
 Lack of uniformity
 Choosing a single cause of death
 Changing system of diagnosis and coding systems
 Diseases with low fatality
Uses of mortality data:
 To explain the trends and differentials in overall mortality
 Indicates priorities for health action
 For allocation of resources
 Designing intervention programmes
 Assessment and monitoring of public health programmes and problems
 For epidemiological research
Types of mortality measurements:
1. Crude Death Rate:
Definition: it is defined as the number of deaths from all cases per 1000 estimated midyear
population in one year, in a given place.
Formula: Number of deaths per year (1000)
Midyear population
Limitations: They lack comparibilities between the communities in a population like age,
gender, socio economic status etc…
 2. Specific Death Rate:
Definition: The specific death rates may be specific to Disease or cause, Groups, income,
religion, housing etc…
Formula: Number of death of deaths from TB cases during a calendar year (1000)
Midyear population
 Age specific death rate:
Number of death in a particular age group (defined place and time period) (1,000)
Mid-period population (same age group, place and time period)
 Cause specific death rate:
Number of death due to a particular cause (defined place and time period) (1,000)
Mid-period population (same place and time period)
3. Case Fatality Rate:
Definition: Case fatality represents the killing power of a disease. It is the ratio of death to cases.
The case fatality rate is applicable to the acute diseases because it varies for the same disease
according to time because of changes in the host, environment and agent.
Formula: Total number of deaths due to a particular disease
Total number of cases due to the same disease
4. Proportional mortality rate/ ratio
Definition: it is the proportion of total deaths due to a particular cause or occurring in a
particular age group.
Formula: Number of deaths from a specific disease in a year (100)
Total deaths from all causes in that year
Types:
 proportional mortality from a specific disease
 Under five proportionate mortality rate
 Proportional mortality rate for aged 50 years and above
Uses:
 Indicators within any population group of the relative importance of the specific disease or
disease group is a cause of death.
Limitations:
 Limited to make comparison between population groups or different time periods
 Does not indicate the risk of members of the population contracting or dying from
disease
5. Survival rate:
Definition: It is the proportions of survivors in a group, studied and followed over a period. The
survival period starts from the date of diagnosis or start of the treatment.
Uses:
 To describe the prognosis regarding a disease condition
 Yard stick to assess the standards of the therapy
Formula:
Survival rate= Total number of patients alive after 5 years (100)
Total number of patients diagnosed or treated
6. Adjusted or standardized rates
Definition: It is done for comparing the death rate of two different populations with different
age composition. Using a series of age specific death rate is cumber some, so age adjustment or
age standardization is done to remove the confounding effect of different age structures and
obtains an Adjusted or standardized rates by which mortality rates can be compared.
Methods of standardization:
 Direct standardization:
A standard population is selected and it is defined as one for which the numbers in each age
and sex group are known. The standard population may be made by combining 2 populations.
The next step is to apply the standard population, the age specific rates of the population whose
crude death rate is to be adjusted or standardized. As a result, for each group, an expected
number of deaths (or any other event) in the standard population is obtained; these are added
together for all the age groups, to give the total expected deaths. The final operation is to divide
the expected total number of deaths by the total of th4 standard population, which yields the
standardized or age adjusted rate.
  Indirect standardization:
a) Standard mortality ratio: Standard mortality ratio is a ratio of the total number of deaths
that would have been expected to occur if that study group had experienced the death
rates of a standard population.
SMR: Observed deaths (100)
Expected deaths
b) Other standardization techniques
 A more complicated method of indirect adjustment which yields absolute age adjusted
rate, involves the calculation of an index death rate and a standardizing factor for each
population of interest.
 Life table: is an age adjusted summary of current all causes mortality
 Regression techniques
 Multi variate analysis
ii. Measurement of morbidity:
Morbidity: morbidity is defined as “any departure, subjective or objective, from a state of
physiological well being”.
3 units of morbidity measurement
 Persons who are ill
 The illnesses (periods or spells of illness) that these persons experience
 The duration of these illnesses
3 aspects of morbidity
 Frequency: disease frequency is measured by incidence and prevalence
 Duration : illness duration is measured by disability rate
 Severity: the case fatality rate is used as an indicator for disease severity
Uses of morbidity data:
 They describe the extent and nature of the disease load in the community, and thus assist in
the establishment of priorities
 They usually provide more comprehensive and more accurate and clinically relevant
information on patient characteristics that can be obtained from mortality data, and are
therefore essential for basic research.
 They serve as a starting point for etiological studies, and thus play a crucial role in disease
prevention
 They are needed for monitoring and evaluation of disease control activities.
Types of morbidity measurements
1. Incidence
Definition: Incidence measures the number of new cases of a disease (or other health-related
Phenomenon) that occur during a specified period of time in a population-at-risk.
Characteristics of Incidence measurement
 Only to new cases
 During a given period
 In a specified population or population at risk
 It can also refer new spells or episodes of disease arising in a given period of time, per 1000
population.
Uses of incidence rate:
 To control disease
 For research into etiology, pathogenesis, distribution of diseases and efficacy of preventive
and therapeutic measures.
Types of incidence: there are two types of incidence. They are:
a) Incidence rate = incidence density
b) Cumulative incidence (incidence)
c) Special incidence rate
a) Incidence rate = incidence density
Definition: Incidence Rate is the Measures of new cases of disease that develop in a population
during a specified period of time.
Formula: No. of new cases of specific disease during a given time period (1000)
Population at risk during that period
Characteristics: The main characteristics of incidence rate are
 Not a proportion
 Has dimension (unit of ID is time)
 Varies between 0 to infinity
E.g.: In 2003, the number of new cases of STI was 500 among the men aged 40-44 years in Lab
Leu District. The person years were 30,000 among that group of people.
Incidence rate = 500*1000/30000 person-years = 16.7 per 1000 per year
b) Cumulative Incidence( Incidence):
Definition: Cumulative incidence is defined as the probability that a particular event, such as
occurrence of a particular disease, has occurred before a given time. It is equivalent to the
incidence, calculated using a period of time during which all of the individuals in the
population are considered to be at risk for the outcome. It is sometimes also referred to as the
incidence proportion.
Formula:
CI = No. of individuals who get the disease during a certain period
No. of individuals in the population at the beginning of the period
E.g.: The population statistic of Assam in 2001 revealed that there were 5,572 women aged 20-
39 years who were sex workers. Based on the record of CHAS, among those women, 45 were
HIV + ve during 2002- 2005. What is the cumulative incidence of HIV + ve among those
women during a period of 4 years?
Cumulative incidence = 45 / 5,572 = 0.008 or 0.8%
Characteristics of Cumulative Incidence: the main characteristics of Cumulative Incidence are:
 it is a measurement of proportion
 Has no dimension
 Varies between 0 and 1
c) Special incidence rate:
Special incidence rates are attack rate, secondary attack rare, hospital admission rate etc...
 Attack rate: An attack rate is the cumulative incidence of infection in a group of people
observed over a period of time during an epidemic. It is measured from the beginning of
an outbreak to the end of the outbreak. The term should probably not be described as a
[1]
rate because its time dimension is uncertain . For this reason, it is often referred to as
an attack ratio.
Formula: The number of exposed persons infected with the disease (100)
The total number of exposed persons
E.g.: if there are 70 people taken ill out of 98 in an outbreak, the attack rate is

 Secondary attack rate: The number of cases of an infection that occur among contacts
within the incubation period following exposure to a primary case in relation to the
total number of exposed contacts.
2. Prevalence
Prevalence is a frequently used epidemiological measure of how commonly a disease or
condition occurs in a population.
Definition: Prevalence measures how much number of disease cases or condition there is in a
population at a particular point in time.
Formula: The prevalence is calculated by dividing the number of persons with the disease or
condition at a particular time point by the number of individuals examined.
E.g.: in a study 6139 individuals completed the questionnaire (were examined). Of these 6139
people, 519 currently suffered incontinence and so had the condition at the particular time
point of the study. Thus the prevalence of incontinence was 519/6139 = 0.085.
Prevalence is often expressed as a percentage, calculated by multiplying the ratio by
100. The above study expresses prevalence as a percentage, thus the prevalence of
incontinence is 8.5% (or rounded is 9%). Another common way of expressing prevalence,
particularly if the prevalence is low, is as the number of cases per 100,000 of the population.
For example, it is easier to state the result as `66 cases per 100,000 people' than to say the
prevalence is 0.00066.

Figure showing factors influencing disease prevalence

Uses of prevalence: The uses of prevalence are:
 It helps to estimate the magnitude of health or disease problems in the community
 To identify potential high risk populations
 For administrative and planning purposes
Types of prevalence
There are two types of prevalence:
a) Point prevalence
b) Period prevalence
a) Point prevalence: it is defined as the number of all current cases (old and new) of a
disease at one point in time in relation to a defined population. It is also referred as
prevalence rate. Point prevalence can be made specific to age, sex and other relevant
attributes.
Formula:
Number of all new and old cases of a specified disease existing at a given point in time
Estimated population at the same point in time.
b) Period prevalence:
Definition: it measures the frequency of all current cases (old and new) expressed in
relation to a defined population.
Formula:
Number of existing cases (old and new) of a specified disease during a given period of time interval (100)
Estimated mid interval population at risk
Relationship between prevalence and incidence
A waterfall metaphor can be helpful in illustrating the concepts of incidence and prevalence.
Commencing at the top of the falls, we see the new cases flowing into the prevalence pool
below. The water flowing out of this pool reflects the individuals who die, recover, or migrate
out of that population for which the prevalence is measured.
Prevalence is related to two factors:
 Incidence
 Duration of illness
 If the population is stable and incidence and duration is unchanging, prevalence can be as
follows:
P=I×D
P= prevalence
I=incidence
D= mean duration
3. Measurement of disability
4. Measurement of natality
5. Measurement of presence absence or distribution of the characteristics or attributes of
the disease
6. Measurement of medical needs , health care facilities, utilization of health services and
other health related events
7. Measurement of the presence , absence or distribution of the environmental and other
factors suspected of causing the disease
8. Measurement of demographic variables
B. MEASURES OF ASSOCIATION
Definition: Statistical relationship between two or more events, characteristics, or other
variables. And considering to a disease association it is the Statistical relationship between
Exposure and disease. The Association is not causation! And it does not tell about what causes
the disease. The association can be absolute or relative.
The relative risk of myocardial infarction in men compared with women is
Risk ratio = Risk men =5 cases/1000 PY = 5
Risk women 1 case/1000 PY
Absolute: The absolute risk difference between men and women is: 4 cases/1000 PY
5 cases/1000 PY - 1 case/1000 PY = 4 cases/1000 PY
Types of measures of association:
1. Relative risk
2. Odds ratio
3. Attributable risk/population attributable risk percent
4. Standardized mortality ratios
1. Relative risk
Definition: The ratio of the risk of disease in persons exposed compared to the risk in those
unexposed. It is a measure of association between incidence of disease and exposure of interest.
Formula: Incidence rate of disease in exposed
Incidence rate of disease in unexposed
Exposure Disease
Yes No Total
Yes a b a+b
No c d c+d
Total a+ c b+d a+b+c+d

Relative risk= a / (a + b)
c / (c + d)
e.g.:
Develop CHD Do not develop totals Incidence
CHD per1000/ year
Smokers 84 2916 3000 28.0
Non smokers 87 4913 5000 17.4

Incidence in smokers = 84/3000 = 28.0

Incidence in non-smokers = 87/5000 = 17.4
Relative risk = 28.0/17.4 = 1.61
Interpretation of Relative Risk
 1 = No association between exposure & disease – incidence rates are identical between
groups
 1 = Positive association – exposed group has higher incidence than non-exposed group
 < 1 = Negative association or protective effect – non-exposed group has higher
incidence – example: 0.5 = half as likely to experience disease.
 A relative risk of 1.0 or greater indicates an increased risk
 A relative risk less than 1.0 indicates a decreased risk
2. Odds ratio
Definition: The ratio of the odds of a condition in the exposed compared with the odds of
the condition in the unexposed. It is usually applied to prevalence studies rather than
incidence studies
Formula: odds of disease in exposed
odds of disease in unexposed
Exposure Disease
Yes No Total
Yes a b a+b
No c d c+d
Total a+ c b+d a+b+c+d

odds ratio = [a / b] = [ad]

[c / d] [bc]
Attributable risk
Definition: it is the difference in incidence rates of disease / death between an exposed group
and non exposed group.
Formula:
incidence of disease rate among exposed minus incidence of disease rate among non exposed (100)
Incidence rate among exposed
Exposure Disease
Yes No Total
Yes a b a+b
No c d c+d
Total a+ c b+d a+b+c+d
AR = (a/a+b) –(c/c+d)

C. MEASURES OF POTENTIAL IMPACT

Reflect the expected contribution of a study factor to the frequency of a disease in a particular
population. These measures are useful for predicting the efficacy or effectiveness of therapeutic
maneuvers and intervention strategies within a specific population, e.g., vaccine essentially;
potential impact measures are a combination of frequency and association measures.
CONCLUSION
Data (information) are the building blocks of epidemiological research. Careful
measurement, recording and handling of information are crucial to the research process. The
nature of the data required must be precisely defined and its collection requires the use of
reliable tools or instruments. Standardization of definitions and procedures used in
measurement helps to ensure comparability. Care in undertaking measurements and rigorous
training of personnel carrying out the measurements help to ensure precision. Special care is
necessary to ensure completeness and accuracy in recording the data. Information may be
obtained from routine or especially designed forms and evaluated by counting deaths or cases
of disease or measures of dysfunction. Questionnaires are a frequently used instrument for
collecting information. They should include data identifying the individual being studied,
followed by specific questions concerning diseases and determinants. The collection of high
quality information (data) and its use to construct estimates of 'risk' or risk ratios form the basis
of epidemiology.
REFRENCES
Book references
1. Park K. Textbook of preventive and social medicine.18 th ed.Jabalpur:Bhanot
publishers;2005
2. Gulani KK. Community health nursing principles and practices.1 st ed.delhi:kumar
publishing house;2009
Journal references
1. Rockett I R H. Epidemiology measurements. Sudanese journal of public health. 2009
Oct; 4(4).
2. Carson S S. Definitions and Epidemiology of the Chronically Critically Ill. Respiratory
Care. 2012june; 57 (6): 848-858.
3. The Epidemiology Workforce in State and Local Health Departments — United States,
2010. Morbidity and Mortality Weekly Report. 2012 March 30.61(12): 205-208
Net references
1. Measures in epidemiology [Internet]. Available from:
http://media.collegeboard.com/digitalServices/pdf/yes/4297_MODULE_09.pdf
2. Basics of Epidemiology [Internet]. Available from:
http://www.cs.amedd.army.mil/borden/
3. Epidemiology [Internet]. Available from: http://en.wikipedia.org/wiki/Epidemiology