Common Health Indices in the Community

EPIDEMIOLOGY
Leopoldo P. Sison Jr., MD, MPH || January 12, 2017

Content Outline: Proportion

I. Ratio, Proportion and Rates  A ratio in which the numerator is part of the
a. Ratio denominator
b. Proportion  Read as percent (%)
c. Rate  Special kind of ratio wherein the numerator is part of
d. Population of Observation the denominator and where K is 100.
II. Concepts of Incidence and Prevalence
a. Incidence 𝑋
b. Prevalence 𝐹𝑜𝑟𝑚𝑢𝑙𝑎: × 100
𝑌
III. Analysis of Rates (X is a part of Y)
a. Errors in the denominator
b. Errors in the numerator
 Example: In a community of 500 people, there were
c. Errors due to time
d. Other Errors
50 malaria-positive persons. Thirty-two were males
IV. Common Statistical Indices in Population and 18 were females.
Studies  Answers:
a. Population Characteristics 1. Proportion of malaria-positive persons = 10%
b. Methods of estimating population size 2. Proportion of malaria-positives who are males =
V. Estimates of Age-Sex Distribution 64%
a. Swaroop Uemura Index 3. Proportion of malaria-positives who are females =
VI. Indices of Fertility 36%
VII. Morbidity Rates
VIII. Mortality Rates Rate
IX. Standardization of Rates  A proportion which measures the occurrence of an
X. Health Adjusted Life Years event in a population over time.
XI. Exercise 1  Measured probability of occurrence of some particular
event:
LEGEND: 𝑛𝑜. 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑜𝑐𝑐𝑢𝑟𝑖𝑛𝑔 𝑑𝑢𝑟𝑖𝑛𝑔 𝑔𝑖𝑣𝑒𝑛 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
‼ 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 − 𝑎𝑡 − 𝑟𝑖𝑠𝑘 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
Presentation Mentioned in Remember Book × 10𝑛
the lecture  Rate differs from ratio and proportion in that rate
specifies a period of time in which the event occurs
 Rate is similar to proportion in that the numerator is
RATIO, PROPORTION AND RATES
included in the denominator
 Indicators of certain events in health development,
level of living, vital events, occurrence of disease and Population of Observation
disability, etc.  Refers to people, things, facilities and establishments
 Epidemiology as a quantitative science uses certain from which the observation is being made
kinds of proportions (also referred to as rates) to  In vital rates, the population of observation are
describe and compare the occurrence of disease people
between populations and within a population.  In coverage rates with sanitary inspections of food
establishments = food establishments
Ratio  Bed occupancy rate of hospitals = the population of
observation are beds
 Expressions of a relationship between two quantities
which can be related or totally independent of each
CONCEPTS OF INCIDENCE AND PREVALENCE
other
 Simplest of all statistical measures and there are no  Distinction is important because they have their own
conditions on their use respective uses in planning and evaluation
 Examples:
Incidence Rate
𝑓𝑒𝑚𝑎𝑙𝑒 𝑓𝑒𝑚𝑎𝑙𝑒  Also known as case rate, sickness rate, morbidity rate
𝑜𝑟
𝑚𝑎𝑙𝑒 𝑚𝑎𝑙𝑒 + 𝑓𝑒𝑚𝑎𝑙𝑒  Refers to NEWLY discovered cases of a particular
An expression of the relative frequency of occurrence of disease
an event compared to some other event  Answers the question “How frequent do cases of a
particular disease occur during a given period of time?”
𝑎  Used when dealing with acute conditions or accidents
× 𝐾
𝑏  A dynamic measurement
 Where:  Example: The incidence of TB is the number of new
a = number of event, persons having one or more cases reported per 100,000 population per year
specified attribute
Incidence Rate=
b = number of events, persons having one or more
# of cases discovered during a given period of time
specified different from “a” × Factor
K=1 Ave. population of that period

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 Common Health Indices in the Community
 Factor: unit of which may be 100, 1,000, 10,000 or 1. What is the numerator and denominator and how
100,000 depending on what’s convenient accurate were they obtained?
 When computing for incidence rate for a year, the 2. What is the time period involved?
average population is the midyear population 3. What does the rate intend to measure?
4. Are the rates being compared comparable?
Prevalence Rate
Errors in the Denominator
 Useful in dealing with chronic illness or conditions or  Being over- or underestimated
disabilities
 The use of a wrong denominator to the point that the
 Answers the question “What proportion of the
resulting figure is not a rate but a frequency (the most
population or of a group of persons are actually ill with
serious)
a particular disease at a point in time?”
 Example: Two guns were tested for accuracy
 A static measurement
No. of
 Example: The prevalence of TB cases (all forms, all Gun Caliber
Bull’s Eye
Rate (%)
new plus old cases) existing at a particular time per
100,000 population 0.38 cal 150 75
𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑅𝑎𝑡𝑒 0.32 cal 50 25
𝑜𝑓 𝑛𝑒𝑤 + 𝑜𝑙𝑑 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎 Total 200 100
𝑝𝑎𝑟𝑡𝑖𝑐𝑢𝑙𝑎𝑟 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑎𝑡 𝑎
𝑝𝑎𝑟𝑡𝑖𝑐𝑢𝑙𝑎𝑟 𝑝𝑜𝑖𝑛𝑡 𝑖𝑛 𝑡𝑖𝑚𝑒 Know the number (or population) of bullets fired from
= × 𝐹𝑎𝑐𝑡𝑜𝑟
𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑡ℎ𝑎𝑡 𝑡𝑖𝑚𝑒 each gun to show the accuracy
 Determined by means of surveys
 Takes time Bull’s
No. of No. of
Gun Eye
 Ex. In a census, the time point reference is a specific bullets Bull’s
caliber Rate
date of the census year, beyond which no data is fired Eye
(%)
gathered
0.38 cal 200 150 75
Factors Influencing the Observed Prevalence Rate
0.32 cal 100 50 50
 Increased by:
o Longer duration of the disease
o Prolongation of life of patients without cure Therefore, 0.38 cal has a higher accuracy rate
o Increase in new cases (increase in Errors in the Numerator
incidence)
 Over-counting or under-reporting of the event being
o In-migration of cases
observed are the most common errors
o Out-migration of healthy people
 Example: Statistics on cancer mortality in the
o In-migration of susceptible people
Philippines for a particular year: Provinces (excluding
o Improved diagnostic facilities (better
reporting) the cities) = 14.2/100,000 population 
 For the
 Decreased by: chartered cities combined = 40.1/100,000 population
o Short duration of the disease Q: Is the risk of dying for cancer lower in the provinces
o High case-fatality rate from the disease than in the cities?
o Decrease in new cases (decrease in
incidence) Consider the ff. variables affecting the numerator:
o In-migration of healthy people o Better facilities for diagnosis in the cities
o Out-migration of cases o Cancer consciousness in that area
o Improved cure rate of cases o Deaths are reported where they occur and
not according to the residence
Notes: o Transfer of residence of the cases and staying
 Incidence rates can be used for chronic conditions, there for a long time to be near treatment centers
while prevalence rates can be used for acute (usually in the cities) and therefore are now
conditions depending on the objective of making the classified as city residents already
study
 Ex. If one wants to know the incidence of leprosy (a Errors due to Time
chronic disease), one must compute for the  A conclusion made several years ago may no
incidence rate longer apply to the present
 But if one plans to create a leprosy program, he has Example: Deliveries attended by traditional birth
to compute for the prevalence rate (old and new)
attendants (hilot) were considered unsafe years
since the needs of all lepers may have to be met
ago, but due to the intensive training now, these
are no longer applicable.
ANALYSIS OF RATES  Comparing two events occurring at different periods
may not necessarily mean that whatever differences
 Before making a comparison and conclusions, one may be observed are due to the intrinsic nature of the
should ask the following: two events.

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 Common Health Indices in the Community
Example:
o Cholera asiatica case-fatality rate in 2. Continuous Population Registration
1900 to 1930 was 40 per 100,000 cases  Samples include registering births, death,
o Cholera el Tor case fatality rate in immigration making the necessary subtractions and
1961-1964 was 5 per 100,000 cases additions to the population
o One cannot conclude that Cholera 3. Surveys
asiatica was more fatal than el Tor  Philippine Statistics Authority (PSA), formerly
o Consider the advancements in the fluid National Statistics Office
and electrolyte management during the  Rough counting of houses in a village and doing a
2 time periods census per house
 Used in epidemiological investigations
Other Errors
 Used when reconstructing the population of 2
 Using the Wrong Rate in the Measurement of an municipalities
Event 4. Mathematical Estimates
Examples:  Intercensal (intrapolation)
o One researcher concluded that o Comparing BEFORE census
the vaccination effectiveness rate  Postcensal (extrapolation)
was no better in bringing the o Comparing AFTER census
case-fatality rate down when  Arithmetic Increase
compared to scarlet fever  Geometric Increase
o Case fatality rate does not
measure the preventive efficacy of Arithmetic Increase
the diphtheria vaccine  Population increases at constant AMOUNT per year
o The more suitable measure  Get the difference and divide by the number of years
should be the incidence of
diphtheria before and after Example:
vaccination was introduced Population of July 1, 2000 is 800,000
 Use of wrong index and sampling error Population of July 1, 2010 is 1,000,000
Estimate the population for July 1, 2005 and July 1, 2015.
COMMON STATISTICAL INDICES IN POPULATION STUDIES
(1,000,000−800,000)
Three Principal Uses of Population Data in Health = 20,000
10 𝑦𝑒𝑎𝑟𝑠
Administration
1. Computation of health indices (vital and o For July 2005: 800,000 (in 2000) + (5 years x
health statistics rates and ratios) 20,000) = 900,000
2. Setting up targets of coverage of activities and For July 2015: 1,000,000 (in 2010) + (5 years x 20,0000) =
goal indicators 1,100,000
3. Setting up norms for assignment
of health facilities/staff/funds Geometric Increase
 Population increase at constant rate per year
Population Characteristics  [(1M – 800K )/800K]/10 years = 2.5%
 Population size o Every year the population is increasing by
 Growth rate 2.5% in a compound interest fashion
 Age-sex composition  Population for 2015
 Geographical distribution X = Y (1 + Δ)n
 Fertility X = population to be estimated
Y = population basis
Health Indices for Health Administrators Δ = change rate
 CDR – Crude Death Rate n = number of years
 CBR – Crude Birth Rate = 1M (1 + 0.025)5 or 1 M x 1.1314
 IMR – Infant Mortality Rate = 1,131,400
 MMR – Maternal Mortality Rate
o All are expressed in a world standard Using Growth Rates
population unit of 1000  Growth rate = Crude Birth Rate – Crude Death Rate
 Example:
Methods for Estimating Population Size o Population of 1995 = 500, 000
1. Census CBR 1995 = 24/1000
 National undertaking recommended to be done CDR 1995 = 10/1000
every 10 years Natural Growth Rate = 14/1000
 Big expenditure if done <10 years Population of 1998
 Increased errors in estimates if done >10 year = 500,000 x (1+0.014)3 or
intervals, since estimates usually assume settings in = 521,295
the last census still hold true for period being
estimated

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 Common Health Indices in the Community
ESTIMATES OF AGE-SEX DISTRIBUTION Total Birth Rate (TBR)
 Provides the means of categorizing whether the 𝑇𝑜𝑡𝑎𝑙 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 +𝐹𝑒𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ𝑠
population is young, intermediate or old  TBR = x 1000
𝑀𝑖𝑑𝑦𝑒𝑎𝑟 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
 Provides a rough picture of the sickness patterns in a
locality MORBIDITY RATES
 For planning priority programs
 Represent this in a pictorial graph or population  Measure frequency of illness within specific
pyramid populations

Swaroop Uemura Index Specific

 Risk of dying for persons aged 50 years and over Morbidity Example
 A high Swaroop index means
Rate
o Ageing population
o Success in the control of communicable Cause- 𝑇𝐵 𝑐𝑎𝑠𝑒𝑠 𝑎𝑔𝑒𝑑 1 − 4
diseases age- × 1000
o Low IMR specific 𝑃𝑜𝑝 𝑜𝑓 1 − 4
o Better Sanitation
o Longer life expectancy Cause- 𝑇𝐵 𝑐𝑎𝑠𝑒𝑠 𝑎𝑚𝑜𝑛𝑔 𝑓𝑒𝑚𝑎𝑙𝑒𝑠
o Better economic status sex- × 1000
𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑓𝑒𝑚𝑎𝑙𝑒𝑠
 Example: Japan – most likely people live a better life specific
because the population is able to grow old Cause- 𝑇𝐵 𝑐𝑎𝑠𝑒𝑠 𝑎𝑚𝑜𝑛𝑔 𝑓𝑒𝑚𝑎𝑙𝑒𝑠 1 − 4 𝑦𝑟𝑠
age-
𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑓𝑒𝑚𝑎𝑙𝑒𝑠 1 − 4 𝑦𝑟𝑠
specific-
specific × 1000
𝑇𝐵 𝑐𝑎𝑠𝑒𝑠 𝑎𝑚𝑜𝑛𝑔 𝐵𝐶𝐺 𝑣𝑎𝑐𝑐𝑖𝑛𝑎𝑡𝑒𝑑 𝑖𝑛𝑑𝑖𝑣𝑖𝑑𝑢𝑎𝑙𝑠
Cause-
𝐵𝐶𝐺 𝑣𝑎𝑐𝑐𝑖𝑛𝑎𝑡𝑒𝑑 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
treatment- × 1000
specific

Cause- 𝑇𝐵 𝑎𝑚𝑜𝑛𝑔 𝑓𝑒𝑚𝑎𝑙𝑒𝑠 1 − 4 𝑤𝑖𝑡ℎ 𝐵𝐶𝐺

age-sex 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑓𝑒𝑚𝑎𝑙𝑒𝑠 1 − 4 𝑤𝑖𝑡ℎ 𝐵𝐶𝐺
Figure 2. Morbidity Rates

Figure 1. Population pyramid of the Philippines in 2010. This
shows that we have a young population.
INDICES OF FERTILITY
Crude Birth Rate (CBR)
 Only live-births are counted
 The denominator is the total population which
includes children, old people and males
 CBR = Total Live Births in a Year x 1000
Midyear population
 Example: The crude birth rate of Province A in 2014
Midyear population: 241,882
live birth: 7113
 CBR =
7113
x 1000
241882
CBR = 29.41 per 1000 population
General Fertility Rate (GFR)
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
 GFR =
𝑀𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 𝑎𝑔𝑒𝑑 15−44
MORTALITY RATES
 Commonly used mortality indicators
o Crude death rate (CDR)
o Death rate from a particular cause (cause –
specific)
o Age-specific death rate
o Sex-specific death rate
o Case-fatality rate
Crude Death Rate (CDR)
 Measure of the risk of dying from all causes in the
population
𝑇𝑜𝑡𝑎𝑙 𝑛𝑜.𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑓𝑟𝑜𝑚 𝑎𝑙𝑙 𝑐𝑎𝑢𝑠𝑒𝑠
 CDR = x 1000
𝑀𝑖𝑑𝑦𝑒𝑎𝑟 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
Maternal Mortality Rate (MMR)
 The ideal denominator should be the total number of
pregnant women, but this data is difficult to retrieve
 This rate is both sex- and cause-specific and in a way
age-specific because maternal deaths occur in the
reproductive age group of 15 – 44
 The rate measures risk of dying due to the process of
pregnancy, childbirth and puerpuerium
𝑁𝑜.𝑜𝑓 𝑝𝑟𝑒𝑔𝑛𝑎𝑛𝑐𝑦 𝑟𝑒𝑙𝑎𝑡𝑒𝑑 𝑑𝑒𝑎𝑡ℎ𝑠
x 1000  MMR =
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
x 1000
Infant Mortality Rate (IMR)
 Measures the risk of dying in infancy under 1
year of age

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 may be used to measure the adequacy of health Indirect Standardization
services administered (since infant deaths are  Used when small stratum-specific rates are unavailable
preventable) or unstable because of small numbers 

 Note that not all infants who die during the year  Borrow standard age specific death rates (ASDR) from
were born on that same year any of the following: 

 Can artificially be decreased by increasing the o Sum of the 2 ASDRs

denominator by better reporting of live births o Average of the 2 ASDRs
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑏𝑒𝑙𝑜𝑤 1 𝑦𝑟
 IMR = x 1000 o More stable ASDR

𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
 High IMR can mean: o A standard ASDR (e.g. ASDR of the
o High incidence of communicable Philippines)
disease EXAMPLE: Compare the Crude Death Rate of Area A and B
o Poor state of sanitation
 Area A Area B
o Inadequate health facilities
 Total Deaths 2250 1,250
o Shorter life expectancy Total Population 100,000 100,000
o A young population CDR 22.5/1,000 12.5/1,000

Cause – Specific Death Rates (CSDR) Question: Would you say that there is higher risk of dying in
 Measures the risk of dying from a particular cause Area A than B?
 Example: Death from TB No, we cannot conclude right away using only the data
above even if it is evident in the table that the Total Deaths in
number of deaths from TB in 2010 Area A is higher than Area B. We need to compute for the ASDR
𝐶𝑆𝐷𝑅 = 𝑥 1,000 first.
midyear population in 2010
Compute for ASDR
Proportionate Mortality Rate (PMR) AREA A AREA B
 Measures the magnitude of death from a particular AGE Populatio Death ASD Populatio Death ASD
cause n s R n s R
number of deaths from TB in 2010 < 10
𝑃𝑀𝑅 = 𝑥 1,000
total number of deaths in 2010 year 70,000 2,100 30 30,000 900 30
Case Fatality Rate (CFR) s
 Measures the killing power of a disease 10
 Lethality rate, killing rate year 30,000 150 5 70,000 350 5
s+
 Example: CFR of TB
Total 100,000 2,250 22.5 100,000 1,250 12.5
number of deaths from TB in 2010
𝐶𝐹𝑅 = 𝑥 1,000
total number of TB cases in 2010
age specific deaths
Other Measures of Mortality 𝐴𝑆𝐷𝑅 = 𝑥 1,000
age specific population
 With Livebirths as denominator
 Neonatal Mortality Rate – measures the risk of dying
Area A:
in the first four weeks of life
2,250
 Fetal Death Ratio – measures the risk of dying before 𝐴𝑆𝐷𝑅 =
100,000
𝑥 1,000 = 22.5
birth
 Perinatal Mortality Rate – measures the risk of dying
Area B:
during the period of birth (Fetal Death + Neonatal 1,250
Death) 𝐴𝑆𝐷𝑅 = 𝑥 1,000 = 12.5
100,000

STANDARDIZATION OF RATES
From here, we can now conclude that there is higher
 Used to remove the effect of an unwanted variable, risk of dying in Area A compared to Area B. Even if both age
such as age, from a comparison 
 groups for both areas have the same ASDR, in totality, Area A
 Methods of standardization 
 has higher risk of dying. This is due to the variation in the totality
o Direct standardization of the number of deaths.
o Indirect standardization
STEPS IN DATA STANDARDIZATION
Direct Standardization
 Used whenever stable stratum-specific rates are Direct Method
available  Step 1. Compute for ASDR.
 Borrow a standard population from any of the following:
o Sum of the 2 populations
 age specific deaths
𝐴𝑆𝐷𝑅 = 𝑥 1,000
o Average of the 2 populations
 age specific population
o More stable population

o A standard population (e.g. population of the  Step 2. Plug the chosen standard population – since
Philippines) Direct Method will be used.

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 Step 3. Compute for the expected number of deaths B = 617,900/91,028,000 * 1000 = 6.79
using the standard population and the ASDR.

Are the results now comparable?
 Step 4. Find age adjusted death rate using the Yes, because the data have already been
following formula: standardized.
total expected deaths Indirect Method
= 𝑥 1,000  Step 1. Plug in borrowed age-specific death rate
total standard population
(ASDR) – since Indirect Method will be used. This
 Step 5. Compare the age-adjusted death rates for the standard may be the sum of the ASDRs from both
two populations. populations, the average, or borrowed from a more
stable population (e.g., Philippine data).
 Step 2. Compute for the expected number of deaths by
EXAMPLE: Population and Deaths by Age - Manila, CAR, and
multiplying the new ASDR with the population.
the Philippines (2010)
 Step 3. Compute for the standard mortality ratio for the
MANILA CAR
two populations.
AGE Populatio Death Rate Populatio Death Rate
n s * n s *
observed deaths
< 15 114,350 136 1.19 47,164 59 1.59 SMR = 𝑥 100
15 – expected deaths
80,259 57 0.71 20,036 18 0.90
24
25 –  Step 4. Compare the SMRs for the two populations.
133,440 208 1.56 32,693 37 1.13
44
45 – EXAMPLE:
142,670 1,016 7.12 14,947 90 6.02 CALL CENTER HOSPITAL
64
39.1 39.0 AGE Populatio Death Rate Populatio Death Rate
65+ 92,168 3,605 2,077 81 n s * n s *
1 0
Total 562,887 5,022 106,917 285 40 – 0.00 0.00
1,000 2 5,000 10
CDR 49 2 2
8.92 2.67 50 – 0.00 0.00
* 5,000 20 1,000 4
59 4 4
CDR for Manila and CAR are 8.92 and 2.67 Tota
6,000 22 6,000 14
respectively. No conclusion can be deduced because of the l
differences in age specific populations. We need to standardize *observed deaths
data to get age adjusted death rates to be able to compare the PHILLIPINES
two regions. Population* Deaths* Rate*
30,000 30 0.001
PHILLIPINES 40,000 120 0.003
Population* Deaths* Rate* 70,000 150
23,961 32 1.34
15,420 9 0.58 *multiply by 1,000
21,353 30 1.40 Based on the data above, one would think that there
19,609 140 7.14 are more deaths happening in call centers than in hospitals. But
10,685 529 49 one should not conclude because the data has not been
91,028 740 standardized yet.
8.13
MANILA CAR
*multiply by 1,000 AGE STANDARD
MANILA CAR Population Deaths Population Deaths
RATE
AGE STANDARD
Deaths Rate* Deaths Rate* 40 –
POPULATION 0.001 1,000 1 5,000 5
49
< 15 23,961 28.51 1.19 38.10 1.59 50 –
0.003 5,000 15 1,000 3
15 – 59
15,420 10.95 0.71 13.88 0.90
24 Total 6,000 16 6,000 8
25 –
21,353 33.31 1.56 24.13 1.13
44
Standardized Mortality Ratio (SMR)
45 –
19,609 139.62 7.12 118.05 6.02 Call center SMR = 22/16 * 100 = 137.5
64
65+ 10,685 424.93 39.11 423.74 39.00 Hospital SMR = 14/8 * 100 = 175
Total 91,028 637.32 617.9
CDR* 7.00 6.79 Since the hospital SMR is higher than the call center
SMR, it can be concluded that the risk of dying is higher
in
hospitals.
Direct age adjusted death rates
A = 637,320/91,028,000 * 1000 = 7.00

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 Common Health Indices in the Community
HEALTH ADJUSTED LIFE YEARS 4. The risk of dying in the first four weeks of life (NMR)
# 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑖𝑛 𝑎 𝑦𝑒𝑎𝑟 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 < 28 𝑑𝑎𝑦𝑠
Disability Adjusted Life Years (DALY) 𝑁𝑀𝑅 = 𝑥 1,000
# 𝑜𝑓 𝑙𝑖𝑣𝑒𝑏𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
 Healthy life years LOST 
 3,200
 DALY = YLD + YLL 
 = 𝑥 1.000
4,155,203
o YLL = Years of life with disability = 7.7 ~ 8 neonatal deaths / 10,000 livebirths
o YLD = Years of life lost
5. The adequacy and accessibility of the health facilities
Quality Adjusted Life Years (QALY) (MMR)
 Healthy life years LIVED 
 # 𝑜𝑓 𝑝𝑟𝑒𝑔𝑛𝑎𝑛𝑐𝑦 𝑟𝑒𝑙𝑎𝑡𝑒𝑑 𝑑𝑒𝑎𝑡ℎ𝑠
 The arithmetic product of life expectancy combined with 𝑀𝑀𝑅 = 𝑥 100,000
𝑡𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑙𝑖𝑣𝑒𝑏𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
a measure of the quality of life-years remaining 272
 Measures the burden of disease on a life with inclusion = 𝑥 100,000
4,155,203
of quality and quantity of lived life
 = 6.6 ~ 7 maternal deaths / 100,000 livebirths
 Method of evaluation that offers information in
considering, measuring and choosing health 6. The reproductive capacity of the country (GFR)
interventions often in the role of disease treatment. 𝑡𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑙𝑖𝑣𝑒𝑏𝑖𝑟𝑡ℎ𝑠
𝐺𝐹𝑅 = 𝑥 1,000
 Generates an estimated number of years that can be 𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝. 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 𝑎𝑔𝑒𝑑 15 − 44
added to life if an intervention is given 4,155,203
= 𝑥 1,000
 Factors to be considered: 31,200,000
o degree of pain = 133 livebirths / 1000 women aged 15-44
o mobility

7. Growth rate
o general mood 𝐺𝑟𝑜𝑤𝑡ℎ 𝑅𝑎𝑡𝑒 = 𝐶𝐵𝑅 − 𝐶𝐷𝑅
EXERCISE 1: RATES AND RATIOS = 45 − 1
= 44 / 1,000 population
Part I
The following vital statistical data were obtained from Country X for Part II
2016: Table 3: Morbidity and Mortality data in City Z for 2015
Estimated Population (as of July 2015) 92,337,852 Number of
Causes/Illness Number of Cases
Crude Birth Rate 45/1,000 population Deaths
Still Birth 732 Malignant
Deaths Under 1 year 7,435 100 50
Neoplasm
Neonatal Deaths 3,200 Dengue Fever 200 100
Maternal Deaths 272 Diabetes Mellitus 300 150
Total Deaths 97,120 Cardiovascular
Population of Women (age 15-44 years) 31,200,000 400 200
Diseases
Others 1,000 500
Determine the following for 2016: Population = 20,000
1. The risk of dying for 2016 (CDR)
𝑡𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠
𝐶𝐷𝑅 = 𝑥𝐹 1. Which has a higher risk of dying between CVD and DM?
𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 # 𝑑𝑒𝑎𝑡ℎ𝑠 𝑑𝑢𝑒 𝑡𝑜 𝐶𝑉𝐷
=
97,120
𝑥 1000 𝐶𝑆𝐷𝑅 = 𝑥 1,000
92,337,852 𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝
= 1.05 ~ 1 death / 1000 population
200
2. The state of health and unborn children (FDRatio) 𝐶𝑆𝐷𝑅 = 𝑥 1,000 = 10 𝑝𝑒𝑟 1,000 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
20,000
# 𝑜𝑓 𝑠𝑡𝑖𝑙𝑙𝑏𝑖𝑟𝑡ℎ𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑦𝑒𝑎𝑟
𝐹𝐷𝑅𝑎𝑡𝑖𝑜 = 𝑥 10,000
# 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟 # 𝑑𝑒𝑎𝑡ℎ𝑠 𝑑𝑢𝑒 𝑡𝑜 𝐷𝑀
𝐶𝐵𝑅 𝑥 𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝐶𝑆𝐷𝑅 = 𝑥 1,000
# 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 = 𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝
1000
45 𝑥 92, 337, 852 150
# 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 = 𝐶𝑆𝐷𝑅 = 𝑥 1,000 = 7.5 𝑜𝑟 ~8 𝑝𝑒𝑟 1,000 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
1000 20,000
= 4, 155, 203
732 Answer: CVD
𝐹𝐷𝑅𝑎𝑡𝑖𝑜 = 𝑥 10, 000
4, 155, 203
= 1. 76 ~ 2 still births / 10,000 live births 2. Which has a higher killing power between dengue and
malignant neoplasm?
3. The state of health of infants (IMR)
# 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑏𝑒𝑙𝑜𝑤 1 𝑦𝑒𝑎𝑟 𝑜𝑓 𝑎𝑔𝑒 # 𝑑𝑒𝑎𝑡ℎ𝑠 𝑑𝑢𝑒 𝑡𝑜 𝑑𝑒𝑛𝑔𝑢𝑒
𝐼𝑀𝑅 = 𝑥1,000 𝐶𝐹𝑅 = 𝑥 100
𝑡𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑙𝑖𝑣𝑒𝑏𝑖𝑟𝑡ℎ𝑠 # 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑑𝑒𝑛𝑔𝑢𝑒
7,435
= 𝑥1000 100
4,155,203 𝐶𝐹𝑅 = 𝑥 100 = 50 𝑝𝑒𝑟 100 𝑐𝑎𝑠𝑒𝑠
= 1.789 ~ 2 infant deaths / 1000 live births 200

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 Common Health Indices in the Community
# 𝑑𝑒𝑎𝑡ℎ𝑠 𝑑𝑢𝑒 𝑡𝑜 𝑚𝑎𝑙𝑖𝑔𝑛𝑎𝑛𝑡 𝑛𝑒𝑜𝑝𝑙𝑎𝑠𝑚 1. Explain why there is a difference in CDR for
𝐶𝐹𝑅 = 𝑥 100 population A and B.
# 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑚𝑎𝑙𝑖𝑔𝑛𝑎𝑛𝑡 𝑛𝑒𝑜𝑝𝑙𝑎𝑠𝑚

50 The difference in the crude death rates for populations

𝐶𝐹𝑅 = 𝑥 100 = 50 𝑝𝑒𝑟 100 𝑐𝑎𝑠𝑒𝑠 A and B is due to the different compositions of their deaths
100
Answer: They have the same killing power and population.

3. Which has a higher magnitude of death between CVD and Direct Method:
malignant neoplasm?
# 𝑑𝑒𝑎𝑡ℎ𝑠 𝑑𝑢𝑒 𝑡𝑜 𝐶𝑉𝐷 Table 5: direct method using sum of two populations as
𝑃𝑀𝑅 = 𝑥 100
𝑡𝑜𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ𝑠 standard population
200 Age Standard Population A Population B
𝑃𝑀𝑅 = 𝑥 100 = 20 𝑝𝑒𝑟 100 𝑑𝑒𝑎𝑡ℎ𝑠
1,000 group population DEATHS RATE DEATHS RATE
Young 5,000 5 1.0 10 2.0
Middle
# 𝑑𝑒𝑎𝑡ℎ𝑠 𝑑𝑢𝑒 𝑡𝑜 𝑚𝑎𝑙𝑖𝑔𝑛𝑎𝑛𝑡 𝑛𝑒𝑜𝑝𝑙𝑎𝑠𝑚 – 10,000 100 10.0 200 20.0
𝑃𝑀𝑅 = 𝑥 100
𝑡𝑜𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ𝑠 aged
Older 5,000 500 100.0 1,000 200.0
50 Total 20,000 605 1,210
𝑃𝑀𝑅 = 𝑥 100 = 5 𝑝𝑒𝑟 100 𝑑𝑒𝑎𝑡ℎ𝑠
1,000
Direct Age Adjusted Death Rate of A:
Answer: CVD 605
= 𝑥 1,000 = 30.25 𝑜𝑟 30 𝑝𝑒𝑟 1,000 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
20,000
4. What is the risk of dying from all causes?
Direct Age Adjusted Death Rate of B:
# 𝑑𝑒𝑎𝑡ℎ𝑠, 𝑎𝑙𝑙 𝑐𝑎𝑢𝑠𝑒𝑠 1,210
𝐶𝐷𝑅 = 𝑥 1,000 = 𝑥 1,000 = 60.5 𝑜𝑟 61 𝑝𝑒𝑟 1,000 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝 20,000
1,000
𝐶𝐷𝑅 = 𝑥 1,000 = 50 𝑝𝑒𝑟 1000 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
20,000 Indirect Method:
Part III
Table 6: Number of Observed Deaths in Two Populations by
Population in 2005 = 34,785,237
Population in 2016 = 48,765,209 Age
Compute for the population in 2025 using: Population A Population B
Age
Populati ASD Deat Populati ASD Deat
1. Arithmetic Increase Method Group
on Size R h on Size R h
48,765,209 –34,785,237 Young 1,000 1.0 1 4,000 2.0 8
P2025 =
11 years
Middle -
= 1,270,906.55 5,000 10.0 50 5,000 20.0 100
Aged
P2025 = 48,765,209 + (1,270,906.55 x 9 years )
100. 200.
= 60,203,368 Older 4,000 400 1,000 200
0 0
2. Geometric Increase Method Total 10,000
48,765,209 –34,785,237 Observ
P2025 = 34,785,237 ed 451 308
11
Deaths
= 0.04
P2025 = 48,765,209 x (1 + 1.04)9
= 69,408,098 Table 7: Indirect Method Using Sum of ASDRs as Standard
Population A Population B
Age
Part IV Populati ASD Deat Populati ASD Deat
Group
Table 4: Comparison of Death Rates in Two Populations by on Size R h on Size R h
Age Young 1,000 3.0 3 4,000 3.0 12
Population A Population B Middle -
Age 5,000 30.0 150 5,000 30.0 150
Population ASDR per Population ASDR per Aged
Group
Size 1,000 Size 1,000 300. 1,20 300.
Older 4,000 1,000 300
Young 1,000 1.0 4,000 2.0 0 0 0
Middle Total 10,000
5,000 10.0 5,000 20.0
– Aged Observ
1,35
Older 4,000 100.0 1,000 200.0 ed 462
3
Total 10,000 10,000 Deaths
CDR 45.1/1,000 30.8/1,000

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Common Health Indices in the Community
𝑜𝑏𝑠𝑒𝑟𝑣𝑒𝑑 𝑑𝑒𝑎𝑡ℎ𝑠
𝑆𝑀𝑅 = 𝑥 1,00
𝑒𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑑𝑒𝑎𝑡ℎ𝑠

451
𝑆𝑀𝑅 (𝐴) = 𝑥 100 = 33.33
1,353

308
𝑆𝑀𝑅 (𝐵) = 𝑥 100 = 66.7
462

2. Can A Fair Comparison Between Death Rates Of The

Two Populations Be Made? If Yes, How?

Yes. Comparison Between Two Populations with

Differing Compositions Can Be Made by Standardizing the
Given Data. Both An Indirect And A Direct Method Can Be
Used. Standardization Eliminates the Influence of
Confounding Variables Such as Age. After Using Direct
and Indirect Standardization, It Turns Out That Population
B Actually Has a Higher Death Rate and SMR Than A.

REFERENCES:
1. 2019A and 2019C Trans
2. Lecture Notes
3. Epidemiology and Research Methods I Manual

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