Lecture 5

Syapiila M.P
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In epidemiology, many nominal variables
have only two possible categories: alive or
dead; case or control; exposed or unexposed
etc.

Such variables are called dichotomous

variables.

The frequency measures used with

dichotomous variables are ratios,
proportions, and rates.

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Used to compare two quantities
1:1 ratio of female to male births

Used to show distribution of disease in a

population e.g. boys/girls

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Obtained by dividing one quantity by another.
These quantities may be related or may be
totally independent.
Usually expressed as : X/Y x 10ᶰ
Example: Number of still births per thousand
live births
#stillbirths x 1000
#live births

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This were the numerator is included in the
denominator, usually presented as a
percentage

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 Calculation of proportion:
Males undergoing bypass surgery at Hospital A

Total patients undergoing bypass surgery at HospitalA

352 males undergoing bypass surgery

= 65.3%
539 total patients undergoing bypass surgery

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A measure of how quickly something of
interest happens.

It measures the occurrence of an event in a

population over time.

The basic formula for a rate is as follows:

Rate= Number of events occurring during a given time period x 10ᶰ
population at risk during the same time period

Time, place and population must be

specified for each type of rate.

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In public health, ratios and Proportions are
used to characterize populations by age, sex,
race, exposure and other variables.

Ratios, proportions and most importantly

rates are used to describe the health status
of a given community.

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Health is defined as “a state of complete physical, mental
& social wellbeing, and not merely an absence of disease
or infirmity”

This statement has been amplified to include the ability

to lead a “socially and economically productive life”

Health cannot be measured directly (in exact measurable

forms)

Measurement have been framed in terms of illness (or

lack of health), consequences of ill-health (morbidity,
mortality) & economic, occupation & domestic factors
that promote ill health
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 Health indicators are used to measure health
status of the community. They are defined as
parameters that can measure changes in the level
of health.

In fact, they are indirect parameters or variables

that assess state of the health of the community.
Indicators can be:
1. Rates
2. Ratios
3. Number (in a specific place and time).

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1. Measurement of the health of the community.
2. Compare health status of one community with another
whether in the same continent or globally.
3. Assessment of health care needs.
4. Proper allocatio n of human and non- human resources
according to the needs.
5. Monitoring and evaluatio n of health services, act ivities,
and programs.
6. Compare health status of different areas or groups of
people over time.

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1. Valid: They should actually measure what they are supposed
to measure, e.g. use of case fatality rate to measure severity of
a disease.

2. Reliable: give similar results when the measure is used for

the same person in different times with similar circumstances.

3. Objective: does not depend on subjective feelings of the

persons, but depends on defined standards.

4. Sensitive: they should be sensitive to the changes in the

measured condition .

5. Specific: only reflects the changes in the measured condition.

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6. Feasible: they should have the ability to obtain
data needed.

7. Relevant: they should contribute to the

understanding of the phenomenon of interest.

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A health indicator is a variable that provides
a single numeric measurement of an aspect
of health within a population for a special
period of time, normally a year.

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Mortality indicators
Morbidity indicators
Disability rates
Nutritional status indicators
Health care delivery indicators
Utilization rates
Indicators of social and mental health
Environmental indicators
Socio-economic indicators
Health policy indicators
Indicators of quality of life
Other indicators
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Used to describe the presence of disease in a
population, or the probability of its
occurrence (risk), morbidity frequency
measures are used.

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Incidence (I): Measures new cases of a disease
that develop over a period of time.
Prevalence (P):Measures existing cases of a
disease at a particular point in time or over a
period of time.
Prevalence can be viewed as describing a pool
of disease in a population.
Incidence describes the input flow of new cases
into the pool.
Fatality and recovery reflects the output flow
from the pool.

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Prevalence Incidence
Existing cases New cases

Measures how much Measures changes in

disease is in the pop disease occurrence

Used for description, Used for investigating

planning health care the causes of disease

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 Incidence quantifies the number of new
events or cases of disease that develop in a
population of individuals at risk during a
specified time interval.

Two types of incidence measures,

I. Cumulative incidence
II. Incidence rate or Incidence density.

Cumulative incidence(CI) is the proportion

of people who become diseased during a
specified period of time.

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CI= number of new cases of a disease during a given period of time
total population at risk during that time

Cumulative incidence provides an estimate of the probability

,or risk, th at an individual will develop a disease during a
specified period of time.

For example, in a study of oral contraceptive(OC) and

bacteriuria a total of 2390 women aged 16 to 49 years were
identified who were free from bacteriuria. Of these, 482 were
OC users at the initial survey in 1973.At the second survey in
1976, 27 of the OC users had developed bacteriuria .

This results in a cumulative incidence of bacteriuria among OC

users of 27 per 482 or 5.6% during this 3 –year period.

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A cumulative incidence of bacteriuria of
5.6% among OC users would be viewed very
differently if it referred to a 6 - mo n th
period, a 3 - y r period or a 10-yr period.

The cumulative incidence assumes that the

entire population at risk at the beginning of
the study period has been followed for the
specified time interval for the development
of the outcome under investigation.

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Even if all subjects enter the study at the same time,
some may become lost during the follow-up, or the
time during which the outcome could be observed,
will not be uniform for all participants.

To account for these varying time periods of follow-

up
,one approach would be to restrict the calculation of
the incidence to a period of time during which the
entire population provided the information.

This would, however necessitate disregarding the

additional follow-up information available for some
of the population.

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 A more precise estimate of the impact of
exposure in a population that utilizes all
available information is called the incidence
rate (IR) or Incidence density.

This is considered to be a measure of the

instantaneous rate of development of disease
in a population and is defined as:
ID = number of new cases of a disease during given time period
total person-time of observation

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As with any measure of incidence, the
numerator of the incidence density is the
number of new cases in the population.

The denominator, however is now the sum

of each individual’s time at risk or the sum
of the time that each person remained
under observation and free from disease.

In presenting an incidence rate, it is

essential to specify the relevant time units-
that is person-day, person-month, person
year, etc.
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The diagram drawn illustrates the calculation of
person-time units, based on the experience of a
hypothetical group of five subjects, two of whom
developed the disease of interest during a 5- yr
follow-up period.

The cumulative incidence of disease could thus be

calculated as 2 cases per 5 individuals over a 5 -
year period

This measure of development of disease would be

misleading, since it does not reflect the fact that
only one of the five subjects(Subject C) was in fact
observed for the entire follow-up period.

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Subject A was observed for only 2 years before
being lost to follo w- up., while subjects B, D
and E were follow ed for 3.0, 4.0 and 2.5 yrs,
respectively.
The total time at risk for this population of five
subjects, could be obtained by adding their
individual times-16.5 person-years.
The incidence density(ID) would be calculated
as follows:
ID = 2 cases/16.5 person-years
= 1 2 . 2 / 1 0 0 person-years of observation

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Example of calculating cumulative incidence vs.
incidence density

OBSERVED TIME IN YEARS

PERSONS
A

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Incidence density gives the best estimate of
the true risk of acquiring disease at any
moment in time.

Cumulative incidence gives the best estimate

of how many people will eventually get the
disease in an enumerated population.

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Measures existing cases of a health condition
Its primary feature of a cross-sectional study

Two types of Prevalence:

-Point Prevalence
-Period Prevalence
Prevalence quantifies the proportion of individuals in
a population who have the disease at a specified
instant and provides an estimate of the
probability(risk),that an individual will be ill at a point
in time.

The formula for calculating the prevalence(P) is:

P= Number of existing cases of a disease
total population

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For example, in a visual examination survey
conducted at NTH among individuals 52 to
85years of age, 310 of the 2477 persons
examined had cataracts at the time of the
survey.

The prevalence of cataract in that age group

was therefore 310 per 2477,or 12.5%.

Thus prevalence can be thought of as the

status of the disease in the population at a
point in time and as such is also referred to as
point prevalence.

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Sometimes, there is need to know how much
of a particular disease is present in a
population at a single point in time-to get a
kind of ‘’stop action’’ or ‘snap shot’ look at
the population with regard to that disease.

Point prevalence is used for that purpose.

Point prevalence is a proportion because

the persons in the numerator are also
included in the denominator.

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The amount of disease present in a population is
constantly changing.

At other times we want to know how much of a

particular disease is present in a population over a
longer period.

Period prevalence is used in this case. The

numerator in period prevalence is the number of
persons who had a particular disease or attribute at
any time during a particular interval.
The interval can be a week, month, year etc.

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Example:
In a survey of patients at an STD clinic,180 of
300 patients interviewed reported use of a
condom at least once during the 2 months
before the interview.

The period prevalence of condom use over

the last 2 months is:

1 8 0 / 3 00 x 100 = 60%

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Example:

Two surveys were done in the same community

12 months apart. Of 5,000 people surveyed
the first time, 25 had antibodies to cholera.
Twelve months later, 35 had antibodies,
including the original 25. Calculate the
prevalence at the second survey and
incidence.

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1.Prevalence at the second survey
X=antibody positive=35
Y=population=5,000
x / y x 10 n =35/5000x1000
= 7 per 1,000

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Incidence during the 12-month period:
X=number of new positives during the 12 -
month period= 35-25=10

Y=population at risk=5,000 -25=4,975

x / y x10ⁿ=10/4,975 x1,000=2 per 1,000

High prevalence of a disease within a

population may reflect high risk, or it may
reflect prolonged survival without cure.

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Conversely, low prevalence may indicate low
incidence, a rapidly fatal process, or rapid
recovery.

Prevalence is often used rather than incidence

to measure the occurrence of chronic
diseases such as osteoarthritis which have
long duration and dates of onset which
difficult to pinpoint.

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Incidence is generally used for acutely
acquired diseases,

Prevalence is used for more permanent

states, conditions or attributes of ill-health.

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The proportion of the population that has a
disease at a point in time (prevalence) and the
rate of occurrence of new disease during a
period of time(Incidence) are closely related.

Prevalence depends on both the incidence rate

and the duration of the disease from onset to
termination.

If the incidence of a disease is low but those

affected have the condition for a long period of
time, the prevalence will be high relative to the
incidence rate.

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If the incidence rate is high but the duration
is short ,either through prompt recovery or
death, the prevalence will be low relative to
the incidence.
This interrelationship between incidence
and prevalence can be expressed
mathematically by saying that the
prevalence(P) is proportional to the product
of the Incidence rate(I) and the average
duration of the disease(D).
P=I x D
When two of the measures are known, the
third can be calculated by substitution.

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Example:

Average annual incidence rate of lung cancer

in Connecticut between 1973 to 1977 was
45.9 per 100,000.and the average annual
prevalence was 23.0 per 100,000.Calculate
the average duration of lung cancer?

D=P/I = 23. 0/ 10 5 = 0. 5 year.

45.9/ 10 5 /year

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P=IXD

Incidence (I) Prevalence (P)

How quickly new Existing count at steady state
Guests arrive Duration(D)-7 days, length of stay

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2/day 14

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 A mortality rate is a measure of the frequency
of occurrence of death in a defined
population.

Mortality rate = deaths occurring during a given time period x 10ⁿ

# of the population among which deaths occurred

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Crude mortality rate is the mortality rate
from all causes of death for a population.

Cause specific mortality rate is the mortality

rate from a specified cause for a population.

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This is the mortality rate limited to a
particular age group.

The numerator is the number of deaths in

that age groups;

the denominator is the number of persons in

that age group in the population.

Some specific types of age-specific mortality

rates are neonatal, post neonatal, and infant
mortality rates.

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Infant mortality rate: Death under one year of
age during a given time interval divided by
number of live births reported during the
same time interval.

These are most commonly used rates for

measuring the risk of dying during the first
year of life.

These rates are some of the most frequently

used measures for comparing health services
among nations.

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Are an index of the risk of dying in the first
28 days of life.

The numerator is the number of deaths in

one year for children younger than 28 days of
age.

The denominator is the number of live births

in the same year.

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This is an index of the risk of death in infants
aged 28 days to 11months during a given
time interval divided by live births during the
same time interval.

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 Is the number of deaths attributed to a particular disease
during a specified time period divided by the number of
new cases of that disease identified during the same time
period
Death-to-case ratio=no. of deaths of particular disease during specified period.
No. of new cases of the disease identified during same period.

The figures used for the numerator and

denominator must apply to the same
population.

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The death figures in the numerator are not necessarily
included in the denominator, however, some of the deaths
may have occurred in persons who developed the disease
before the specified period.

E.g. In 1987,there were 22,157 new cases of tuberculosis

reported in the United Zambia.
During the same year ,1,755 deaths occurred that were
attributed to tuberculosis

Presumably ,many of the deaths occurred in persons who had

initially contracted tuberculosis years earlier. Thus many of
the 1,755 deaths in the numerator are not among the 22,517
new cases in the denominator.

Therefore, the death-to-case ratio for 1987 is:

1,755/22,517 x 10 n number of deaths per 100 can be
calculated by multiplying the ans by 100.
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The Case-Fatality rate is the proportion of persons who
die from a particular condition (Cases). The formula is:
Deaths from a specific disease x 10ⁿ
Cases of that disease

Unlike the death-to-case ratio, which is simply the ratio

of cause- specific deaths to cases during a specified
time, the case-fatality rate is a proportion and requires
that the deaths in the numerator be limited to the cases
in the denominator.

Thus, if 11 new-borns were to develop listeriosis and

two of these new-borns died as a result, the case-
fatality rate would be:
2deaths/11 cases =18.2%

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Defined as the number of deaths assigned
to a specific cause in a calendar year,
divided by the total number of deaths in
that year, the quotient multiplied by 100

Example:
Country X - total deaths from all causes in 1970:
1,500,000; deaths from cancer: 675,000
Proportional mortality ratio= 675,000/1,500,000 x
100
= 45% of total deaths per year from cancer

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One problem that arises in comparing crude rates
of disease between populations is that the groups
may differ with respect to certain underlying
characteristics ,such as age, sex, or race that may
affect the overall rate of disease.

For example, the crude mortality rate from cancer

in the US in 1940 was 120 per 100,000,as
compared with 183 per 100,000 in 1980.

These crude rates ,indicated an overall 53-percent

increase in cancer mortality during this 40 –year
period. This may erroneously suggested a trend so
alarming as to be considered indicative of an
epidemic of cancer.

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Wide at the base
◦ large proportion of young people in the
country
Narrow at the top
◦ Very small proportion of people is elderly.
High birth rate
High death rate
Low life expectancy

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Roughly equal distribution of
population throughout the age groups
Low birth rate
High life expectancy
◦ e.g. Italy and Japan population
pyramids

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Standardised rates also known as adjusted
rates are crude rates that have been modified
to make them more comparable. That is to
remove the age bias.

These rates can be adjusted by direct or

indirect methods.

Although standardisation is usually done on

crudes death rates, it can be applied to any
type of rates.
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In Direct Standardization, the following steps can be
followed to calculate standardized Crude mortality rates for
the populations to be compared, say populations A and B.
1. For each population calculate age specific mortality rates
2. Multiply the age specific mortality rates with the populations sizes
of the corresponding age group in the standard population to find
expected number of deaths in the Standard population.
3. Sum up all expected deaths to give Total expected deaths in the
std pop.
4. Divide the Total expected deaths in the Std pop. by the Total
population size of the Std pop. to get the Standardized crude
mortality rate for that local population
These standardized crude mortality rates will then be
comparable.

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5/20/2021
 Population Local # of deaths in Age specific Standard Expected deaths
age groups population A local pop. mortality rates populatio
(years) n
0-20 400 12 12/400 = 0.03 16 000 16 000 X 0.03 =
480
21-40 300 12 12/300 = 0.04 12 600 12 600 X 0.04 =
504
41-60 200 4 4/200 = 0.02 8 400 8 400 X 0.02 = 168

> 60 150 6 6/150 = 0.04 6 000 6 000 X 0.04 = 240

Total 1, 050 31 43, 000 1, 392

The Standardized Crude Mortality for our local population would then be = Expected deaths/Total Std
Pop.
= 1, 392 / 43, 000 = 0.032
= 32 p/s1000pop.

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5/20/2021
Its used if age specific death rates are not
available or if the pop are too small and so
the Age Specific Death Rates are statistically
unstable.

So here, standardised Age Specific Death

Rates are applied on the populations to be
compared and standardised mortality ratios
are then calculated as below

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It is expressed as a ratio of observed to
expected deaths, multiplied by 100.

SMRs equal to 100 imply that the mortality

rate is the same as the standard mortality
rate.

A number higher than 100 implies an

excess mortality rate whereas a number
below 100 implies below average mortality.

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The calculation used to determine the SMR
is simply: number of observed
deaths/number of expected deaths.

SMR=Observed deaths) x 10 n
expected death

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To arrive at the expected number of deaths,
for each age group, the standard age-specific
death rate (rates of the larger pop.) is
multiplied by the local population in that age
group.

The number of expected deaths in each age

group are then summed across all ages to
arrive at the expected number of deaths for
the local population.

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The standardized mortality ratio or SMR is the ratio of
observed deaths to expected deaths according to a specific
in a population and serves as an indirect means of
adjusting a rate.

The figure for observed deaths is usually obtained for a

particular sample of a population.

The figure for expected deaths reflects the number of

deaths using death rates for the larger population from
which the study sample has been taken.

e.g. national level of mortality rates attributed to a

particular health outcome.

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Example :

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annual death rate
crude death rates
infant mortality rates (ratio)
neonatal mortality rates
Post-neonatal mortality rates
perinatal mortality rates
fetal death rates
fetal death ratios
abortion rates
maternal mortality rates
adjusted mortality rates
standardized mortality ratio
Cause specific death rates
proportionate mortality rate- case fatality rate
mortality crossover – mortality time trends
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