EPIDEMIOLOGY

A BRIEF INTRODUCTION
Measurement of Morbidity and
Mortality

Prepared by
Marjorie Ming MPH, RHV,
Cert. Nsg. Ed., RN, RM
EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality
Purpose of Presentation: is to enable participants
To demonstrate understanding of the measures of calculation
used in epidemiologic studies.
Objectives: Participants will be able to utilize effectively
specific epidemiologic measurements and their calculations
 Ratios
 Proportions
 Incidence rates
 Prevalence rates
 Demographic rates

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EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality
Definitions of Terms: Count, Rates, Ratios, and
Proportions, Frequency
The Count: is the number of events or individuals that
satisfy specified criteria. This definition is synonymous with
that of frequency, e.g.:
 In country X colorectal cancer was the second leading
cause of cancer deaths in 1989, accounting for an
estimated 30,000 deaths (11%) of all cancer deaths for
that period.
 The count in this example is therefore: 30,000 persons
died from colorectal cancer in country X in 1989.
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 EPIDEMIOLOGY
A Brief Introduction
Measurement of Morbidity and Mortality
Definitions cont’d.:
The Rate: is the most important tool for measuring
disease in epidemiology. Ratios & Proportions are
also used.
 A rate is a special form of proportion that includes
specific time.
 The basic measure of disease occurrence: it
most clearly expresses probability or risk of disease
in a defined population over a specified period of
time (Mausner & Kramer, 1985).
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 EPIDEMIOLOGY: A Brief Introduction
Measurement of Morbidity and Mortality
Definitions cont’d.: The Rate:
Risk: in general terms is the chance of occurrence of
some untoward event (Fletcher et. al., 1988). A rate is
also defined as a measure that expresses rapidity,
intensity, velocity, or force of some event; e.g.,
occurrence of new cases of disease in a specified time
period.
The numerator of a rate is the number of events or individuals
satisfying specified criteria. The denominator is the number of
units of exposure examined in counting the numerator. A unit of
exposure is the passage of an individual through a certain
experience or situation, e.g. person year, which is a year lived by
one person. [pack years of smoking = pack cigs/day/year/person].
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EPIDEMIOLOGY: A Brief Introduction
Measurement of Morbidity and Mortality
Definitions cont’d.: The Rate:
Midyear Population: sometimes appears in the
denominator as an estimate of person years lived by
members of a population during a certain year.
Midyear population is used when available, because it is
more stable than population estimate taken at the
beginning and end of a year.
Rates are expressed as:
No. of events in a specified period x K
Population at risk of the events in a spec. time
(units of exposure to event in a spec. time)

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EPIDEMIOLOGY: A Brief Introduction
Measurement of Morbidity and Mortality
Definitions cont’d.: The Rate:
Distinctions are made between crude and specific rates.

A Crude Rate: is a summary statistic that ignores the

homogenous groupings (differences) of the population
under investigation. E.g. The crude birth rate refers to
the population in general, without specific reference to
groupings of similar characteristics/groupings.

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EPIDEMIOLOGY: A Brief Introduction
Measurement of Morbidity and Mortality
Definitions cont’d.: The Rate:

Crude Birth Rate = Births in spec. year x 1000

Midyear population in spec. year

Measured per 1000 population. Midyear population is in

the Denominator as an estimate of person-years lived
by that population’s members during that year.

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 EPIDEMIOLOGY: A Brief Introduction
Measurement of Morbidity and Mortality
Definitions cont’d.: The Rate:

Specific Rates: break down the population into

homogenous groups or strata, depending on one or
more demographic or other factors thought to be
related to the outcome of interest.
Specific Rates enable us to understand the influence
of individual factors such as age; race; gender etc. E.g.
Age-specific Birth Rate =
Births to women of X age in a specific year
Midyear population of women of that age
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EPIDEMIOLOGY: A Brief Introduction
Measurement of Morbidity and Mortality
The Term Rate: is often used to characterize
demographic & epidemiologic measures that are either:
True Rates *Proportions or *Ratios
Therefore we must pay keen attention to how a rate is
defined, specifically how the denominator is defined e.g.

The Rate is a True Rate: when the denominator

contains units of exposure during specified time.
In this case # of new cases of disease per person-time.

[E.g. 3.5 cases per person-year.]

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EPIDEMIOLOGY: A Brief Introduction
Measurement of Morbidity and Mortality
The Term Rate: is often used to characterize
demographic & epidemiologic measures that are either:
True Rates *Proportions or *Ratios (cont’d.)

In contrast
The Rate is a Proportion: when the denominator
contains a count of the number of persons exposed
during specified time. In this case it’s the proportion of
at-risk population that developed the disease during
specified time frame of interest.
E.g. 5 cases per 100 individuals.
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EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality
A Ratio: expresses the relationship between two
numbers in the form of X:Y or A/B x K for example,
the ratio of male to female live births in the US in 1979
was: 1,791,000 : 1, 703,000 or 1.052 to 1.
1,791,000 males to 1,703,000 females or:
1791000 = [1.52 : 1]
1703000 or [1. 52 males to 1 female]
A ratio contains a numerator that represents the
“count” of the number of events that meet a specified
criterion & a denominator that represents the count of
the number of events that satisfy a different criterion.
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EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality
A Proportion: is a specific type of ratio in
Which the numerator is included in the denominator
and the resultant value is expressed as a percentage.
E.g. the male:female ratio is not a proportion but
could be converted to one.
Numerator: male births = 179 X 100 [ = 51.3% ]
Denominator: male + female births 179 + 170 x 100

In 1987 deaths from all causes in country X was 2,123,323; of

These, 760,353 were attributed to heart diseases. Therefore the
proportion of deaths from heart diseases in 1987 was:
760,353/2,123,323 = 0.3581 approx. 1/3 of all deaths.
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EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality

Ratio is expressed as: X : Y or X/Y x K

Proportions are expressed as:

Numerator (no. of category of events) x K
Total (all categories of) events

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EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality
To calculate a rate we must be able to count
accurately, all events of interest that occur in a
defined population during a specified period of time.
E.g. death rate from cancer in population X in 1980
was 186.3 per 100,000 population calculated with
the formula:
Deaths from cancer among residents in 1980 x 100,000
over Total Population in 1980

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EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality
Different rates of morbidity & mortality are used in
epidemiology and public health. These fall into two
basic types: Incidence & Prevalence Rates.
Incidence Rates:
 measure the probability that healthy people will
develop a disease during a specified time; hence it is:
 the number of new cases of a disease in a population
over a period of time. The rate at which new disease
occurs in a defined previously disease free population
(group of people)

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EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality
Prevalence Rate: measures the number of
people in a population who have the disease at
a given time.
 Prevalence measures the probability of people
having a disease at a given point in time. “Termed
Point Prevalence”. Prevalence depends on:
a) The number of people who have been ill in the
past (previous incidence) &
b) The duration of their illness.

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 EPIDEMIOLOGY
A Brief Introduction
Measurement of Morbidity and Mortality
Hence: Incidence tells us the rate at which new
disease occurs in a defined, previously disease-free
group of people.
Prevalence measures the probability of people having
a disease at a given point in time (point prevalence).
 Even if only a few people in a group become ill each
year.
 If the disease is chronic the number will mount &
prevalence will be relatively large in relation to
incidence.
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 EPIDEMIOLOGY
A Brief Introduction
Measurement of Morbidity and Mortality
 Conversely, if the illness under consideration is acute (of
short duration) due to either recovery or death; or
migration of diseased persons from the area, then
prevalence will be relatively low.
 The relation of prevalence (P) to both incidence (I) &
duration (D) of disease is expressed in the formula:
[P ~ I x d], which states that prevalence varies
directly with incidence and duration. If incidence & duration
are stable over a long time, the formula is:
[P + I x d]. Hence, if 2 parts of the equation are
known, it is possible to calculate the third.

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 EPIDEMIOLOGY
A Brief Introduction
Measurement of Morbidity and Mortality
 Treatment that succeeds in prolonging life has a
profound effect on disease prevalence. E.g.
1. Insulin treatment for diabetes
2. Chemotherapy for childhood leukaemia.
3. Introduction of antibiotics & other agents extended
the life expectancy of children born with Down’s
Syndrome and other congenital defects. This resulted
in a marked increase of mental retardation and other
handicaps. Referred to as “The Failure of
Success” by Gruenberg, (1977). (a paradox)!??
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 EPIDEMIOLOGY A Brief Introduction

Measurement of Morbidity and Mortality

Incidence Rate is expressed as:
No. of new cases of a disease at a point in time
Total Population at Risk

Prevalence Rate is expressed as:

Number of existing cases of a disease at a point in time
Total Population (x 1000 or 100,000)

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EPIDEMIOLOGY A Brief Introduction
Measurement of Morbidity and Mortality

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EPIDEMIOLOGY
A BRIEF INTRODUCTION
Measurement of Morbidity and Mortality
Considering Incidence: To determine incidence, it is
necessary to follow a defined population prospectively &
determine the rate at which new cases of disease occur.
In order to calculate incidence rate certain basic
requirements must be met:
1) Knowledge of the Health Status of the Study
Population. Requires adequate basis on which to classify
people as “diseased” or “not diseased”. Such information
is available from accurate health records; screening; or
detailed examination of the population. To compare
groups accurate information for all groups is needed.
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EPIDEMIOLOGY A BRIEF
INTRODUCTION
Considering Incidence: cont’d.
2. Time of Onset: It is necessary to determine the
time of onset for studies of incidence. This is simple
for some events such as influenza, acute myocardial
infarction and cerebral haemorrage which can often
be pinpointed to a specific hour. This is not so simple
for other conditions onset of which may be indefinite.

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 EPIDEMIOLOGY A Brief Introduction
Considering Incidence: cont’d.
 Hence, the earliest definite, objectively verifiable event
identified must be taken as the time of onset.
E.g. (1) In cancer the date of onset is defined by the
date of definitive diagnosis, rather than the date when
symptoms were first noted or when the doctor became
suspicious that the person had cancer.
E.g. (1) Bahn (1961) in Epidemiologic studies of
psychiatric outpatients, found it useful to operationally
define patients in terms of date of first clinic visit rather
than date of referral to clinic or date of commencement
of treatment. MEMing 09/2010 26
EPIDEMIOLOGY A Brief Introduction
Considering Incidence: cont’d.
3. Specification of Numerator: Number of
persons vs. Number of Conditions. In certain
circumstances, more than one event can occur to the
same person within a stated time period. This gives
rise to two types of incidence rates from the same set
of data. E.g. since a person may have more than cold in
a year, two rates could be calculated:
a) # of people who developed a cold In one-year period
People at risk
b) # of colds In one-year period
People at risk
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EPIDEMIOLOGY A Brief Introduction
Considering Incidence: Spec. Numerator cont’d.
 The first rate gives the probability that any person
will develop a cold in one year.
 The second rate tells us the number of colds to
expect among the group of people in that year.
 When number of persons and number of events can
differ, the numerator should be clearly specified.
 Without such specification, it is generally assumed
that refers to persons and that an incidence rate
represents a statement of probability or risk per
person.
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EPIDEMIOLOGY A Brief Introduction
Considering Incidence: cont’d.
4. Specification of Denominator: The
denominator in incidence rate must consist of a
defined population, accurately enumerated. Two points
must be considered in relation to the denominator.
1. Since incidence covers a period of time, the
numbers of persons “at risk” is likely to change. Hence
this is simply handled by using the population at the
mid-point of the period to represent the average
population “at risk”. For annual rates this would be the
estimated mid-year population.
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 EPIDEMIOLOGY A Brief Introduction
Considering Incidence: Specification of
Denominator: cont’d.
2. Since incidence refers to new cases of disease,
theoretically only those who are at risk of developing the
disease under consideration, i.e., population “at risk”
should form the denominator.
The denominator should not include those who have
the disease nor those who are not susceptible because
they have already had it or have previously been
immunized.
 The denominator should be corrected to include only
those at risk if and when the condition is common & or
when precision is required. MEMing 09/2010 30
EPIDEMIOLOGY A Brief Introduction
Considering Incidence: Specification of
Denominator: cont’d.
 Example: To test effectiveness of measles vaccine in
a group of 6 year olds, only those who are still
susceptible should be included in the denominator.
 In contrast: Denominators in prevalence rates
always include the general population, since the
numerator contains “old” and “new” cases.

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 EPIDEMIOLOGY A Brief Introduction
Considering Incidence: cont’d.
5. Period of Observation: Incidence rates must
always be stated in terms of a definite period of time.
 The time period for which a rate is calculated should
be long enough to ensure stability of the numerator.
(Incident cases may be accumulated over several years
for diseases of low frequency).
 Accuracy of the Denominator should also be of
concern. When possible the denominator should be
drawn from a census year or from the years bracketing
a census (e.g.1989 – 1991).
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 EPIDEMIOLOGY A Brief Introduction
Considering Incidence: cont’d.
5. Period of Observation:
For large populations (country or city) an average annual
rate is often calculated as:

# of new cases of a disease in an interval x[ 1

Midpoint population at risk during the interval #yrs. In
[the interval]

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 EPIDEMIOLOGY A Brief Introduction

References/Bibliography
Clarke, M. J. 1996, Nursing in the Community 2nd Ed.
Appleton & Lange, N. J.
Mausner and Bahn, 1985, Epidemiology An Introductory
Text 2nd Ed. W. B. Saunders Co. Phil.
…………………………, Medical Biostatistics ????

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