Lecture 3

Epidemiology &
Biostatistics

Measuring Disease

MHA
October,
 Outline
•
Descriptive Epidemiology & Analytical
Epidemiology

•
Mathematical measurements of disease
frequencies
– Ratios,
– rates,
– proportions
 Epidemiology

•
“The study of the occurrence and distribution
of health-related states or events in specified
populations, including the determinants
influencing such states and the application of
this knowledge to control health problems”
 Seven Steps

1. Define the population of interest

2. Conceptualize and create measures of
exposures and health indicators
3. Take a sample of the population
4. Estimate measures of association between
exposures and health indicators of interest
5. Rigorously evaluate whether the association
observed suggests a causal association
 What is a population?

Group of people with a common characteristic

• Place of residence, age, gender, time period,
religion
• People who live
– in Nebraska … Omaha …
– along the 2,341 miles of the Missouri River …
– within one mile of a nuclear power plant

• Occurrence of a life event (undergoing medical

 Populations

•
Membership can be permanent or transient

• Population with permanent membership is

referred to as “Fixed” or “Closed”
•
People present at Hiroshima
•
Passengers on an airplane

• Population with transient membership is referred

to as “Dynamic” or “Open”
 Fixed or Closed Populations

•
Because populations can be defined by just
about anything, a unifying concept for
identifying a population is whether the
membership can be permanent or transient.

•
When a population has a permanent
membership, we call it a fixed or closed
population.
 Dynamic or Open Populations

•
Populations with transient membership are
referred to as dynamic or open populations.

– An example of this is the population of Omaha,

where people are migrating in, immigrating out,
and people are being born and dying. So new
members can be added. Key concepts in the
transient population is migration, birth and death.
 Examples of populations, defined
by characteristic, event, or
exposure
•
Individuals over the age of 65

•
Individuals exposed to a natural or human-
made disaster

•
Individuals of certain races or ethnicities
 Example

Study of carcinoma of the cervix? Define the

population at risk?
0-24 yrs

All
All 25-69 yrs
Women
25-69 yrs
Men
70+ yrs

All
Women

Bonita et al
 Seven steps

1. Define the population of interest

2. Conceptualize and create measures of
exposures and health indicators
3. Take a sample of the population
4. Estimate measures of association between
exposures and health indicators of interest
5. Rigorously evaluate whether the association
observed suggests a causal association
 Defining Disease

•
Often, the way we define disease depends on
the methods that are available – for example,
– questionnaires from occupational studies or
– from community surveys, or
– lab tests for influenza.

•
The key point is that the disease must be
defined, and the definition MUST be stated so
 Health and Disease - Continued

•
Case definition questions

• Important to include as many as possible?

•
i.e., Increase sensitivity

• Important to increase the probability that the

selected persons actually have the illness?
•
i.e., Increase specificity
 Health and Disease - Continued

•
If there are multiple ways to measure disease,
how do you decide which way to measure it?

•
That often depends on the purpose of
measurement and what is feasible.

•
One question is whether it is important to
include as many people as possible in the
 Health and Disease - Continued

•
You may want to include everyone that comes
even close to having certain symptoms and
signs.

•
But, as the investigation continues, your
definition becomes more and more narrow, so
you can then identify the etiology or cause of
the disease.
Example
 Example

•
Here is an example about the measurement of
disease from different definitions.

•
This is a bar graph showing results of a study
to compare the measurement of rheumatoid
arthritis using two different definitions.
 Example

•
First, it shows that the percentage of
rheumatoid arthritis is higher in females than
in males – at least in the population that was
studied.

•
Second, it shows that one set of disease
 Example

•
In other words, the ARA criteria are more
sensitive, because they identify a lot more
people, some of whom may not really have
rheumatoid arthritis if more definitive tests
are done.
Example 2
 Example 2

•
Here is another example of defining disease.

•
This slide shows the diagnosis of dementia in a
population, where the number of people
diagnosed with the most sensitive definition –
the DSM III on the far left – is almost 10 times
greater than the number of people diagnosed
with the most specific definition – the ICD-10,
 Disease Measure Example
•
Research question
– Are individuals who have depression more likely to be
overweight than individuals without depression?

•
Measuring depression
– Constellation of symptoms
– Condition characterized by disabling feelings of hopelessness, sadness,
and loss of interest in activities

•
Measuring overweight
 Seven Steps

1. Define the population of interest

2. Conceptualize and create measures of
exposures and health indicators
3. Take a sample of the population
4. Estimate measures of association between
exposures and health indicators of interest
5. Rigorously evaluate whether the association
observed suggests a causal association
 Measures of disease
occurrence and frequency

• Counts

• Prevalence

• Incidence/risk

• Incidence Rate
 Measures of Frequency

•
“Count” - the most basic epidemiologic
measure

• Expressed as integers (1, 2, 3, …)

• Answers the question, “How many people have
this disease?”
• Often the numerator of many measures
• Important to distinguish between incident (new)
and prevalent (existing) cases
 “Count” – The most basic
epidemiologic measure

•
Counts is the most basic epidemiologic
measure.

•
It is never negative and can reach infinity.

•
This measure answers the question
“How many people have this disease”?
Illustration of Numerator Data
U.S. Deaths, 20th Century
 Illustration of Numerator Data
U.S. Deaths, 20th Century
•
This graph shows the number of deaths in the
United States from 1900 to 2000, and you can
tell that the number of deaths are increasing
monotonically over time.

•
Again, at first glance, you may think that life in
the US has become more dangerous and that
more people are dying every day.
•
But numerator data needs to be put into
context – once the population is taken into
account, you can see that it wasn’t so bad
living in the US during the 20th Century.

•
Because the population in the US has grown
over this time period, the denominator takes
this into account as per 1000 people in the
 Understanding incidence and
prevalence: the bathtub example
Example of the relation between
incidence and prevalence
 Mathematical Measurements Of
Disease Frequency

Epidemiological Outcomes

•
Ratios

•
Proportions
 Ratio
•
One number divided by another

•
No special relationship is implied between
numerator and denominator

•
Proportions and rates are specific types of
ratios

– Example:
 Proportion

•
A specific type of ratio

•
All those included in the numerator must be
part of the denominator – just like the
expression of a fraction

OR
 Rates

•
Type of ratio, most often expressed as a
proportion

•
Tell us how fast the disease is occurring in a
population

•
There is usually a specific relationship
between the numerator and the denominator
 Rates

Attack rates in an acute epidemic =

# of people with the illness who ate a certain

food
Total number of people who ate that food

•
This resembles a typical proportion in that all
those in the numerator are also represented in
the denominator
 Incidence & Prevalence

•
In epidemiology, the occurrence of a disease
or condition can be measured using rates and
proportions.

•
We use these measures to express the extent
of these outcomes in a community or other
population.
 Incidence

•
Incidence = number of new events or cases of
a disease occurring in a population of
individuals at risk during a specified period of
time interval.
 Incidence(2)

Example: Incidence =

(No. of new cases occurring in the population during a specified time period)
No. of persons at risk to become a case during same time period)

Example: Incidence per 1,000 =

(No. of new cases occurring in the population during a specified time period) 1000
No. of persons at risk to become a case during same time period)
 Incidence (3)

Incidence of uterine cancer=

(No. of new cases of uterine cancer during a specified time period)

No. of population at risk to become a case during same time period)
 Types of Incidence

•
Two specific types

– Cumulative Incidence

– Incidence rate or Incidence Density

 Cumulative incidence

•
People at risk are observed throughout a
defined time period.

•
Time must be specified and all persons in the
population must have been observed for the
entire period

•
No loss of follow up
 Incidence rate

•
When all people are not observed for the full
time period for reasons like

– loss of follow up or
– death from a cause other than that being studied

•
Different individuals are observed for different
 Incidence rate (2)

•
If persons in the population are at risk for
different amounts of time in the period we are
sampling, we can not measure incidence this
way. We need to measure an incidence rate.

•
Incidence rates incorporate time into the
 Incidence Rate(3)

Incidence rate=

No. of new disease onsets

Σ persons’ time spent in the population

•
Expressed in person-time such as person
years, person-months, etc.
 Incidence Rate (4)

•
If we don’t have everyone’s individual time
contribution, but we know the average size of
the population, we can also specify the
incidence rate as:

•
Where period of risk is specified as Δt ,
•
the average size of the population by N` , and
•
Incident number = A, then:
 Incidence Rate (5)
•
Incident rate = A/(N` Δt)

•
Example: 100 persons in a population of 1000
persons followed for three years

•
100/ 3000 person-years = 0.03 cases/ person-
year = 3 cases/100 person-years
 Incidence Rate (6)

•
One way to estimate the average population
at risk is to utilize the midyear population as
an estimate of the denominator.

•
However, if there is a lot of irregular gains
and losses to the population at risk
(denominator) during the time at risk, then we
must compute person-time for individuals
(persons at risk have their times summed
Example
 Example contd
•
Person A: 2 years of observation
– Lost to follow-up

•
Person B: 3 years of observation
•
– Developed disease

•
Person C: 1 ½ years of observation
•
– Lost to f/u
 Attack rate

•
Is not a true rate
•
Is a proportion

Number of people exposed to specific food and became ill

Number of people exposed to food

•
Time interval is implied, not mentioned
explicitly.
 Prevalence

•
Prevalence is the number of affected persons
present in the population at a specific time
out of the total number of persons in the
population at that time

•
Prevalence per 1,000 =
 Prevalence

•
Can be viewed as a “snapshot” of a slice of the
population.

•
Cases will be those who have had the disease
for varying periods of time – from recently
acquired to those living with the disease for
some time.
 Prevalence

•
Prevalence – measure of the burden of
disease in a community.

•
It tells us
– How many clinics are needed
– What types of rehabilitation services are needed
– How many and what type of health professionals
 Two Types of Prevalence

•
Point prevalence
– Prevalence at one point in time as just discussed –
this is the “default” definition

•
Period prevalence
– How many persons have had the disease at any
time during a certain period
 Factors which determine
Prevalence

So, what factors determine prevalence?

•
Duration of disease
– Lethality egress from prevalence pool
– Cure-rates egress from prevalence pool
– Quality of care slows egress from prevalence
pool.
– Better care can increase prevalence.
 Problems with Prevalence

Problem with numerator

•
Definition of cases
– Example of Rheumatoid Arthritis
– Prevalence estimate significantly affected by the
set of criteria which is used

•
Finding of cases from available data interview
surveys, which has its own problems.
 Problems with Hospital Data
•
Hospital admissions are selective on basis of
– Personal characteristics
– Severity of disease

•
Hospital records are not designed for research
may be incomplete

•
The diagnostic quality of hospital records and
clinical services may differ, so may have
 Relationship between Incidence
and Prevalence
•
In steady situation:
– In-migration=Out-migration,

•
The following equation applies

•
Prevalence=Incidence *Duration