The Occurrence of

Disease
Dr. Noushin Fahimfar

MD, MPH, PhD of Epidemiology

Tehran University of Medical Sciences

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We owe all the great advances in
knowledge to those who endeavor to find
out how much there is of anything.

James Maxwell, physicist (1831–79)

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 Learning Objectives
• To describe the important role of epidemiology in disease
surveillance.
• To compare different measures of morbidity, including
incidence rates, cumulative incidence, attack rates, prevalence,
and person-time at risk.
• To illustrate why incidence data are necessary for measuring
risk.
• To discuss the interrelationship between incidence and
prevalence.
• To describe limitations in defining the numerators and
denominators of incidence and prevalence measurements.

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 Surveillance
• The Centers for Disease Control and Prevention
(CDC) defined the surveillance as the following:

Ongoing systematic collection, analysis, and

interpretation of health data essential to the planning,
implementation, and evaluation of public health
practice closely integrated with the timely
dissemination of these data to those who need to
know.

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 Surveillance may be carried out to:
• Monitor changes in disease frequency
• Monitor changes in the levels of risks for specific diseases
• Monitor for completeness of vaccination coverage
• Monitor the prevalence of drug-resistant organisms such as
drug-resistant tuberculosis (TB) and malaria.
• ….

Surveillance provides policy makers with guidance for

developing and implementing the best strategies for
programs for disease prevention and control
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At the beginning, surveillance was mainly for
infectious diseases, but in recent years for other
types of conditions such as:
- congenital malformations,
- Non-communicable diseases
- environmental toxins
- injuries and illnesses after natural disasters such as
hurricanes or earthquakes.

For example:
- The WHO STEPwise approach to NCD risk factor surveillance
(STEPS) is a simple, standardized method for collecting, analysing
and disseminating data on key NCD risk factors in countries.

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To have coordinated public health approaches:
• Standardized case definitions of disease and diagnostic
criteria.
• The forms used for collecting and reporting data on
different diseases must also be standardized.

• The CDC defines the surveillance case definition as “a set of

uniform criteria used to define a disease for public health,”
which aids public health officials in recording and reporting
cases.
• This is different from a clinical definition that is used by
clinicians to make a clinical diagnosis to initiate treatment
and meet individual patients’ needs.
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 Types of surveillance

• Passive surveillance
• Active surveillance

• Passive surveillance denotes surveillance in which

available data on reportable diseases are used, or in
which disease reporting is mandated or requested by
the government or the local health authority, with the
responsibility for the reporting often falling on the
health care provider or district health officer.
• Examples of reportable diseases? STIs
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• The completeness and quality of the data reported
thus largely depend on this individual and his or her
staff, who often take on this role without additional
funds or resources.

Problems:
• Underreporting
• Lack of completeness of reporting
• Local outbreaks may be missed

However, a passive reporting system is relatively

inexpensive and relatively easy to develop initially
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 Active surveillance
Denotes a system in which project staff are specifically
recruited to carry out a surveillance program including:

 Make periodic field visits to health care facilities (such as

clinics, primary health care centers, and hospitals) to identify
new cases or deaths from the diseases (case finding).
 May involve interviewing physicians and patients
 Reviewing medical records
 Surveying villages and towns in developing countries, to
detect cases either periodically on a routine basis or after an
index case has been reported.

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• Active reporting is generally more accurate than
passive reporting.

• The staff in passive surveillance are often

overburdened by their primary responsibilities of
providing health care and administering health
services!!

• With active reporting, local outbreaks are generally

more easily identified.
• Active reporting is more expensive to maintain than
passive reporting and is often more difficult to develop
initially.
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Stages of Disease in Individuals and in Populations

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 Progression from health to varying degrees of disease
severity and deaths

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Modified from White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med
 Which sources of data can be used to obtain
information about the person’s illness?

• Medical and hospital records in the case of hospitalization

• Primary care providers’ records if hospitalization is not
required.
• Using a questionnaire or an interview to obtain
information from the patient/a family member about the
illness before medical care.
• The records of health insurers can provide very useful
information.

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 Measures of Frequency

• Ratio
• Proportion
• Rate

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 Ratio
◦ Dividing one value by another value without referring to a
specific relationship between the numerator and the
denominator

Female 5
= 5:2 = 2.5 : 1
Male 2
After the numerator is divided by the denominator, the result is
often expressed as the result “to one” or written as the result “:1.”
 Properties and uses of ratios

• Ratios are common descriptive measures, used in all fields.

• In epidemiology, ratios are used as both descriptive measures
and as analytic tools.
• As a descriptive measure, ratios can describe the male-to-
female ratio of participants in a study, or the ratio of controls
to cases (e.g., two controls per case).
• As an analytic tool, ratios can be calculated for occurrence of
illness, injury, or death between two groups. These ratio
measures, including risk ratio (relative risk), rate ratio, and
odds ratio, are described later in this course.

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 Example

• A city of 4,000,000 persons has 500 clinics. Calculate

the ratio of clinics per person.

• 500 ⁄ 4,000,000 × 10n = 0.000125 clinics per person

• To get a more easily understood result, you could set 10n =

104 = 10,000. Then the ratio becomes:
• 0.000125 × 10,000 = 1.25 clinics per 10,000 persons
• You could also divide each value by 1.25, and express this
ratio as 1 clinic for every 8,000 persons.

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 Proportion
◦ A proportion is a ratio, in which the numerator is a
part of the denominator

Red Cloths women 2 2

100 = 50 %
Red cloths+ Green cloths 2+2 4

Proportions tell us what fraction of the population is affected.

 Example
• Calculate the proportion of men in the NHANES
follow-up study who were diabetics.
Original Dead at Follow-
Participant

Enrollment Up
(1971–1975) (1982–1984)
Diabetic men 189 100
Nondiabetic men 3,151 811
Diabetic women 218 72
Nondiabetic women 3,823 511

• Numerator = 189 diabetic men

Denominator = Total number of men = 189 + 3,151 = 3,340

• Proportion = (189 ⁄ 3,340) × 100 = 5.66%

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 Properties and uses of proportions

• In epidemiology, proportions are used most often as

descriptive measures.
• For example, one could calculate the proportion of persons
enrolled in a study among all those eligible (“participation
rate”), or the proportion of children in a village vaccinated
against measles.
• Proportions are also used to describe the amount of disease
that can be attributed to a particular exposure.
• For example, on the basis of studies of smoking and lung
cancer, public health officials have estimated that greater than
90% of the lung cancer cases that occur are attributable to
cigarette smoking.
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• In a proportion, the numerator must be included in the
denominator.
• Thus, the number of apples divided by the number of
oranges is not a proportion, but the number of apples
divided by the total number of fruits of all kinds is a
proportion. Remember, the numerator is always a
subset of the denominator.

• A proportion can be expressed as a fraction, a decimal,

or a percentage.
• The statements “one fifth of the residents became ill”
and “twenty percent of the residents became ill” are
equivalent.
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 Rate
◦ The rate is a kind of proportion to which time has
been added. It measures the occurrence of an event in
a population over time

Rates tell us how fast the disease is occurring in a population;

 Measures of Morbidity

• Incidence
• Prevalence

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 Incidence
• The incidence rate of a disease is defined as the number
of new cases of a disease that occur during a specified
period of time in a population at risk for developing the
disease.

× 10n

• What does the statement ‘the incidence of hepatitis B in the

European Union is 3.5 per 100,000’ mean?
• Common and rare diseases
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• Because the incidence is a measure of events (i.e.,
transition from a non-diseased to a diseased state),
the incidence can be a measure of risk.

The important points in denominator:

• Represents the number of people who are at risk for
developing the disease, so they must have the
potential to become part of the group that is counted
in the numerator.
• Another important issue regarding the denominator
is the issue of time.

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Incidence measures can use two types of denominators:

• People at risk who are observed throughout a defined

time period;
• When all people are not observed for the full time
period, person-time (or units of time when each
person is observed).

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 Example
• In an outbreak of gastroenteritis among attendees of
a corporate picnic, 99 persons ate potato salad, 30 of
whom developed gastroenteritis. Calculate the risk
of illness among persons who ate potato salad.

• Numerator = 30 persons who ate potato salad and developed

gastroenteritis
Denominator = 99 persons who ate potato salad
10n = 102 = 100
• Risk = (30 ⁄ 99) × 100 = 0.303 × 100 = 30.3%

• Here, Risk is also named as the “Food-specific attack rate”

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A study spanning over a period of 2 years,
recruited a total of 6 patients:

– 3 Deaths were observed

Question: What is the survival up to 2 year?

Survival: 3/6= 50%

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Example:

A study spanning over a period of 2 years,

recruited a total of 6 patients:
– 2 patients were not observed for the entire 2 years
– 1 survived 2 years

– 3 Deaths were observed

Additional information

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 Death
Censored observation (lost to follow-up, withdrawal)
(#) Number of months to follow-up

Person ID

1 (24)

2 (6)

3 (18)

4 (15)

5 (12)

6 (3)

Jan Jan Jan

2004 2005 2006

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What is the 2-year survival?

What is this estimate assuming?

Assume both censored individuals

survived up to 2-years
S ( 2 yrs ) 
3
6
 0.50 ?
Person ID
1 (24)
2 (6)
3 (18)
4 (15)
5 (12)
6 (3)

0 1 2
Follow-up time (years)
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 What is the 2-year survival?
• Assume both censored individuals died before 2-years:

1
S (2 yrs)   0.17
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“True” survival is probably somewhere in between
these extreme estimates …, but where?

Need to take into account losses to follow-up

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 Inc. rate (Density)

90 91 92 93 94 95 96 97 98 99 00 Time at risk
A
5
B x 5
C
10
D
8
E x
4
Total years at risk 32
-- time followed
x disease onset ID = 2 / 32 person- years
= 0/0625 person-year

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• People at Risk Who Are Observed Throughout a
Defined Time Period
Incidence proportion (Cumulative incidence)

• When All People Are Not Observed for the Full Time
Period, Person-Time, or Units of Time When Each
Person Is Observed
Incidence density

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 Example

Incidence measurement

Cumulative incidence is a proportion => Range: 0-1

Incidence rate is not a proportion => Range: 0-infinity
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 Attack rate
• The attack rate of a disease is the number of cases,
divided by the number of susceptible exposed which is
really the same as the definition of risk above.

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 Prevalence
• The prevalence of a disease is the number of people
who have that disease at a specific time, divided by
the total population.

• If the average daily incidence of a disease is called I

and the average duration is D days, then the average
prevalence, P, will be
P = I ×D
When using serology to determine the percentage of a
population that show markers of having had a disease, we
often use the term seroprevalence.
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 What is the difference between incidence and
prevalence?
• Prevalence can be viewed as a snapshot or a slice
through the population at a point in time at which we
determine who has the disease and who does not.
But in so doing, we are not determining when the
disease developed.

• The numerator of prevalence includes a mix of

people with different durations of disease, and as a
result we do not have a measure of risk.

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 Two types of prevalence
Point prevalence:
• Prevalence of the disease at a certain point in time.
Period prevalence:
• How many people have had the disease at any point during a
certain time period?
• The important point is that every person represented by the
numerator had the disease at some time during the period
specified. Numerator Denominator

Number of current cases (new and

Population at the same specified
Point prevalence preexisting) at a specified point in
point in time
time

Number of current cases (new and

Average or mid-interval
Period prevalence preexisting) over a specified period
population
of time 42
Examples of Point and Period Prevalence and
Cumulative Incidence in Interview Studies of
Asthma

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Figure below represents ten episodes of an illness in a population
of 20 over a period of 16 months. Each horizontal line represents
the portion of time one person spends being ill. The line begins
on the date of onset and ends on the date of death or on the date
of recovery.
1- Point prevalence on
October 1, 1990.

2- Period prevalence,
October 1, 1990 to
September 30, 1991.

3- Cumulative incidence
from October 1, 1990 to
September 30, 1991.

4- Incidence rate from

October 1, 1990 to
September 30, 1991.
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The dynamic relationship between
incidence and prevalence

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 PROBLEMS WITH INCIDENCE AND
PREVALENCE MEASUREMENTS

Problems With Numerators

 The first problem is defining who has the disease.
Some diseases are difficult to diagnose, and when such a
diagnostic difficulty arises, expert groups are often
convened to develop sets of diagnostic criteria.

 How do we find the cases?

We can use regularly available data or, we can conduct a
study specifically designed to gather data for estimating
incidence or prevalence.

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Number of people with and prevalence (%) of dementia in the Canadian
Study of Health and Aging cohort (n = 1,879) as diagnosed by different
classification systems. (Data from Erkinjuntti T, Østbye T, Steenhuis R, Hachinski V.
The effect of different diagnostic criteria on the prevalence of dementia. N Engl J Med.
1997;337:1667–1674.)

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 Problems With Denominators

• Selective undercounting of certain groups in the

population may occur. For example, young men in
ethnic minority groups and recent immigrants have
been missed in many counts of the population.

• When different studies use different definitions,

comparison of the results is difficult.

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 Question 1
• A prevalence survey conducted from January 1 through
December 31, 2012, identified 1,000 cases of schizophrenia
in a city of 2 million persons. The incidence rate of
schizophrenia in this population is 5/100,000 persons each
year. What percentage of the 1,000 cases were newly
diagnosed in 2012?

• All cases: 1000

• Total population size: 2000,000
• Incidence rate: 5/100,000

5 100,000 ?=100 100/1000=10%

? 2,000,000
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 Question 2
• Population of the city of Atlantis on March 30, 2012 = 183,000
• No. of new active cases of TB occurring between January 1
and June 30, 2012 = 26
• No. of active TB cases according to the city register on June
30, 2012 = 264
A- The incidence rate of active cases of TB for the 6-month
period was:
• a. 7 per 100,000 population b. 14 per 100,000 population
• c. 26 per 100,000 population d. 28 per 100,000 population
• e. 130 per 100,000 population
B- The prevalence rate of active TB as of June 30, 2012, was:
• a. 14 per 100,000 population b. 130 per 100,000 population
• c. 144 per 100,000 population d. 264 per 100,000 population
• e. None of the above
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Thanks for attention !

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