MEASURES OF DISEASE FREQUENCY

What are the factors that affect the number of individuals who have
disease in populations?

1. impact of the disease-the greater the impact the more cases

are expected
2. size of the population- the bigger thepopulation the more
number of cases
3. period of observation – the longer the period of observation the
more number of cases

RATES

Definition of a Rate: Rate is the frequency of a disease or characteristic

expressed per unit of size of the population or group in which it is observed

• 3 items of information are necessary for a rate to have

epidemiologic usefulness

1. The numerator of the fraction (the number of persons affected)

2. The denominator ( the population among whom the affected persons

are observed).

3. A specification of time

Denominator – commonly called the related or reference population

Things to consider in determination of rates

1.The numerator and denominator of a rate should be similarly restricted; if

the denominator is confined to a certain age,sex or racial group, the
denominator should be similarly limited.

Ex.1 If the denominator population is the number of residents of a town,

cases appearing in the numerator should be limited to residents of that
town.

Ex.2 If the numerator consists of the number of cases of a disease limited to

females, the denominator would preferably be the related female population

2. When the denominator is restricted solely to those persons who are

capable of having or contracting the disease, it is sometimes referred to as
population at risk.

3. The denominator of a rate may not be a population in the ordinary

demographic sense.

Ex.1 A hospital may express its maternal mortality rate as the number of
maternal deaths per thousand deliveries.
Ex.2 The Case Fatality Rate is the number of deaths due to a disease per so
many patients with the disease.

RATIOS

• Definition of a ratio: Ratio expresses the number of affected persons

relative to the number of unaffected persons and not relative to the
total population (affected plus unaffected persons)

• Ex.Fetal Death Ratio - The number of fetal deaths relative to the

number of livebirths. In contrast, Fetal Death Rate is the number of
fetal deaths expressed as a proportion of the related total births
(livebirths plus fetal deaths).

• Disadvantage of Ratios : less amenable than rates to treatment as

probability statistics.

Proportional Rates

• Numbers of cases of a disease are sometimes expressed relative to the

total number of cases of all diseases rather than to the population.

• Ex1. Proportional Mortality Rate – the number of deaths ascribed to

a particular disease maybe expressed as a proportion of all deaths.

• Ex. 2. In clinical studies the incidence of a disease is sometimes

reported as the number of patients with that disease as a proportion of
all patients seen at the same institution.

• However, such proportional rates do not express the risk of members

of the population contracting or dying from the disease.

DEFINITIONS OF MEASURES

• Incidence of a Disease – is the number of cases of the disease

which come into being during a specified period of time. The
Incidence Rate is this number per specified unit of population.

• In practice , it is usually not possible to measure incidence directly,

since the exact time of onset of an illness is uncertain. Instead such
occurrences as onset of symptoms, time of diagnosis or date of
notification or of hospitalization are used thus Incidence is the
frequency of events during a period of time.

• Attack Rate – a special form of incidence rate , in which there is a

limited period of risk.

• Secondary Attack Rate – a measure in which the numerator consists

of the number of cases of a disease which occur within the same
household following the occurrence of a first, or primary case.

This is used in studies of infectious diseases and there is a stated or implied

time limitation that, on the basis of the Incubation Period of the particular
disease, indicates that the secondary cases probably derived from the
primary case. For diseases conferring prolonged immunity, the denominator
in a secondary attack rate usually excludes persons who have previously had
the disease.

• PREVALENCE

1. Point Prevalence of a disease is a census type of measure. It is the

frequency of the disease at a designated point in time.

Expressed for a specified population at a specified time, Point

Prevalence Rate is the proportion of that population which exhibits the
disease at that particular time.

In contrast to Incidence Rates which measures events, point

prevalence rates are measures of what prevails or exists.

• 2. Period Prevalence – is a measure that expresses the total number

of cases of a disease known to have existed at some time during a
specified period.

It is the sum of point prevalence (the number of cases existent at the

beginning of the period) and incidence (the number of cases coming into
existence during the period).

Period Prevalence is of limited usefulness, since both the epidemiologist and

the administrator will generally require knowledge of whether the cases
being counted are new or old thus the word prevalence refers to point
prevalence. Period prevalence data are therefore more useful when
separated into their two components – point prevalence and incidence.

• DEATH RATES

1. Disease-specific death or mortality rate

2. Disease-specific case fatality rate

Similarity: both have the same numerator –the number of persons dying of
the disease during a stated period

Difference: denominators are different

Mortality Rate – expresses the frequency with which members of a general

population die of the disease.

Case Fatality rate – expresses the frequency with which affected

individuals die of the disease

INTERRELATION OF MEASURES

• P varies as the product of I and D

P – prevalence, I- incidence
D – average duration of the disease from onset to termination, measured in
the same time units used to specify the incidence. Duration of the disease is
measured from the same point as that used to approximate its time of
incidence (ex. Date of diagnosis) and prevalence likewise includes only cases
existent at or subsequent to that point.

• Things to remember:

1. A change in prevalence from one period to another may be the result

of changes in 1) Incidence 2) duration or 3) both duration and
incidence

Ex. Improvements in therapy , by preventing death but at the same not

producing recovery , may give rise to the apparently paradoxical effect of an
increase in prevalence of the disease

• Things to remember:

2. A decrease in prevalence may result not only from decrease in incidence

but also from a shortening of the duration of illness- through either more
rapid recovery or more rapid death.

3. If duration decreased sufficiently, a decrease in prevalence could take

place despite an increase in incidence.

Ex. The recent decline in prevalence of in-patients in mental hospitals

P equals the product of I and D (P = I x D)

Given the two of the values in this equation , it is possible to compute the
third

Ex. From the estimates of the prevalence of leukemia the average duration
of the disease can be calculated from the relationship D = P/I (Refer to
Table 7)

Table 5

Data on Patients with Acute Leukemia Brooklyn, New York, whites, 1948 -
1952

Year (1) (2) (3) (4)

Patients alive New cases Deaths in Patients lost
at beginning diagnosed in year to trace
of year year
1948 7 69 54 7
1949 15 91 86 3
1950 17 83 73 3
1951 24 99 101 1
1952 21 68 81 1
Total 84 410 395 15

Table 6
Data on Patients with Chronic Leukemia Brooklyn, New York, whites, 1948 -
1952

Year (1) (2) (3) (4)

Patients alive New cases Deaths in Patients lost
at beginning diagnosed in year to trace
of year year
1948 129 79 50 8
1949 150 83 71 5
1950 157 90 90 6
1951 151 61 84 7
1952 121 53 89 4
Total 708 366 384 30

Table 7

Measures of frequency of acute and chronic leukemia derived from data in

Table 5 and 6

Rates per million population

Measure Acute leukemia Chronic leukemia
Prevalence 6.7 56.1
Incidence per annum 32.5 29.0
Death (mortality) per annum 31.3 30.4

For acute leukemia : D=6.7/32.5 = 0.21 years = 2.5 months

For chronic leukemia: D = 56.1/29.0 = 1.93 years = 23 months

The durations represent the interval between diagnosis and death, since
incidence here was based on date of diagnosis. Note that these data relate
to a time preceding the widespread use of antileukemic drugs.

Things to remember:

The requirements of “stability” for a disease include constancy of incidence

for a period corresponding to the longest duration of the disease in an
individual and constancy of the distribution of cases by duration of illness.

If the formula is applied to a disease which is not stable but has an

increasing or decreasing incidence, the estimates of duration will be lower or
higher, respectively, than the true values.

• Another relation that exists if the disease is stable –or nearly so –is
between incidence (I) and mortality (M), from which the Case Fatality
Rate (F) may be estimated.(Refer to Table 7) the formula is: F= M/I

• For Acute Leukemia: F= 31.3/32.5 = 0.96 or 96 %

 • For Chronic Leukemia: F = 30.4/29.0 = 1.05 or 105%

• The above findings are consistent with the knowledge that both forms
of leukemia are in variably fatal.

• An additional requirement for stability in this situation is that the

proportion of patients with various possible outcomes – e.g., death or
recovery-must also be constant

SPECIFICATION OF TIME

• This is essential for both prevalence and incidence rates.

• In prevalence rate it is a point in time at which the observations are

made.

• In incidence rate it is a period during which events are counted.

SPECIFICATION OF TIME -Several ways of specifying time:

1. Calendar Time

Ex. To estimate the incidence of coronary occlusion, one could count all
cases of coronary occlusion occurring between Jan 1 and Dec.31 of a
particular year, and relate this number to the population at the middle of the
year , to derive an annual incidence rate.- This is the most common way of
specifying the beginning and end of a period of observation.

2. Age – Chronologic age of the population which is used in situations in

which there is interest in a disease occurring shortly after birth

Ex. Suppose that in a maternity hospital over a certain period of time there
were 2000 deliveries of liveborn children, 22 of whom died in the first week
after birth. The death rate in the first week of life may then be expressed as
11 per 1000 LB.

Not all these children were observed during the same period in calendar
time, and it does not matter for this purpose whether the 2000 births
occurred over a period of 1 year or 10 years. The period of observation is
specified as beginning at a certain age (birth) and continuing for 7 days
thereafter.

In the case of prevalence data, an example of the use of chronologic age in

specifying time would be a statement that by age 10 years, 20 % of a
certain population are tuberculin positive.

Other Ways of Specifying Time

Without direct reference to either age or calendar time, the

occurrence of some circumstance may be used to time the point at
which an observation is made or a period of observation is begun.
Ex1 One can measure the prevalence of certain serologic findings at the time
of premarital examination or Ex.2 the incidence of psychotic reactions
occurring within a specified period after childbirth. The time of the premarital
test or the delivery are the points which define the observations in time and
these not occur at any specified point in age or calendar time.

Ex.3 Case Fatality Rates and Ex. 4 Disease Complication Rates are of this
nature, the time of observation beginning when the disease is diagnosed.

• Without direct reference to either age or calendar time, the

occurrence of some circumstance may be used to time the point
at which an observation is made or a period of observation is
begun

Ex. 5 The prevalence of impairments among military inductees or among

school entrants

Ex.6 The incidence of certain disabilities within a specified period following

retirement

Other Specifications

• 1. When expressed as a rate, incidence (unlike prevalence) is not

necessarily a fraction of the population. The numerator may be made
up of cases or attacks rather than individuals, since in some illnesses
such as acute alcoholic delirium or the common cold, some individuals
may experience more than one attack during the period of
observation. In such a circumstance the rate describes the risk of
episodes of the illness occurring among the population rather than the
risk of individuals becoming ill.

• 2. Although attacked only once during the period of observation, some

individuals may be experiencing a recurrence of an illness such as
reactive depression, their initial attack having occurred several years
before the period. Under this condition an incidence rate expresses the
risk of individuals having an attack during the period of interest.

• 3. The denominators of incidence rates may also be limited to specific

components of a population under observation.

Ex 1.If the denominators of an incidence rate contain people who are not at
risk of contracting the disease, important epidemiologic differences between
rates may be obscured. Thus, in those infectious diseases in which an attack
confers permanent immunity (measles, smallpox, chicken pox) , the
majority of a specified population may not be at risk because of past
encounter with the disease. Hence, the denominator in a secondary attack
rate excludes previously affected persons when the disease is one for which
immunity follows a first attack.

• Ex. 2 An analogous situation may exist in common chronic or

relapsing disease of long duration where the denominator may contain
 an appreciable proportion of persons who are either currently ill with
the disease or have had it in the past and are therefore not at risk of
having an initial attack.

Selection of Rates

• INCIDENCE

1. Incidence measured as early in the disease as practicable is the

measure of frequency most useful to studies of causal factors.

2. Because of their ready availability, death rates are sometimes used as

indices of incidence. Death rates are most reliable as indices of
incidence rates when the interval between incidence and death is short
and when the disease has a high case fatality rate.

PREVALENCE

For epidemiologic purposes esp. in identifying causal factors, prevalence

measurements are inferior to incidence, since two sets of factors
determine them: those connected with the occurrence of cases and those
connected with course and duration of the cases once established.

Hence, the main value of prevalence rates is in administrative

situations requiring knowledge of how many patients with a given
disease exist in the community.

Incidence rates are of uncertain value in these situations, since for a

given incidence rate diseases of long duration often impose a greater
burden on the community than those of short duration.

SUMMARY

Epidemiology uses ratios, proportions and rates as tools for describing

disease frequency in populations. The use of these quantities permits
comparisons across populations of different sizes.

There are two types of morbidity rates: prevalence and incidence.

Remember that prevalence usually refers to existing cases while incidence

refers to new cases.

Mortality rates measures the force of death in the population.

LABORATORY EXERCISE ASSIGNMENT

NAME________________________

YEAR & SECTION ____________________

In 1992, the following data on infant deaths were obtained for Region 5.

Province Number of infants Number of births

deaths
Albay 556 26608
Camarines Norte 518 12027
Camarines Sur 709 36177
Catanduanes 195 6439
Masbate 165 8570
Sorsogon 400 16272

What can you say about the following statement?

Infants from Camarines Sur have the highest risk of dying among the
different provinces since it has the highest number of infant deaths.

EXERCISE II : COMPUTATION OF DISEASE FREQUENCIES

Table 5

Data on Patients with Acute Leukemia Brooklyn, New York, whites, 1948 –
1952, Population – 3,200,000

Year (1) (2) (3) (4)

Patients alive New cases Deaths in Patients lost
at beginning diagnosed in year to trace
of year year
1948 7 69 54 7
1949 15 91 86 3
1950 17 83 73 3
1951 24 99 101 1
1952 21 68 81 1
Total 84 410 395 15
Table 6

Data on Patients with Chronic Leukemia Brooklyn, New York, whites, 1948 –
1952 Population 3,200,000

```````````````````````````

Year (1) (2) (3) (4)

Patients alive New cases Deaths in Patients lost
at beginning diagnosed in year to trace
of year year
1948 129 79 50 8
1949 150 83 71 5
1950 157 90 90 6
1951 151 61 84 7
1952 121 53 89 4
Total 708 366 384 30

Table 7

Measures of frequency of acute and chronic leukemia derived from data in

Table 5 and 6

Rates per million population

Measure of Frequency Acute leukemia Chronic leukemia

Prevalence
Incidence per annum
Death (mortality) per annum

1. Compute for the Prevalence of acute and chronic leukemia

2. Compute for the Incidence per annum of acute and chronic leukemia
3. Compute for the Death (Mortality) per annum of acute and chronic
leukemia
4. Compute for the average duration of the disease for acute and chronic
leukemia
5. Compute for the Case Fatality Rate of acute and chronic leuk
EXERCISE III

I. A survey of pulmonary tuberculosis (PTB) among residents, 18

years and above, from urban poor areas in Tondo was done in
1997. 300 males and 250 females were included in the study. Of
these residents, 45 males were found to be positive for pulmonary
tuberculosis by x-ray examinations. There were 35 positive among
the females.

1. Compute for a measure of pulmonary tuberculosis frequency

separately for males and females that can be used directly for
comparison between the two. Label your answers properly.

2. Is this measure that you computed above a prevalence or

incidence measure? Give two reasons for your answer.

II. In a study to determine the relationship of breastfeeding practice

and diarrhea, 60 newborns who were compared with 60 newborns
who were bottle-fed. These individuals were followed-up for six
months. At the end of the follow-up period, each newborn was
recorded as either having experienced diarrhea or not at all. There
were 18 who had diarrhea among the breastfed group compared to
32 among the bottle-fed group.

1. Compute for a measure of diarrhea frequency separately for the

breastfed and bottlefed group that can be used directly for
comparison between the two. Label your answers properly.

2. Is this measure that you computed above prevalence or

incidence measure? Give two reasons for your answer.

For each of the following problems, indicate which measure(s) of morbidity

(point prevalence, period prevalence, and cumulative incidence rate) can be
computed from the data. Compute for these measures.

1. A sample including 1038 women at the age of 70-74 years were

selected from the population of Province X. After examination, 70 were
assigned the diagnosis of rheumatoid arthritis.

2. During a four-year period, there were 532 injuries due to accidents

among the personnel at selected medical laboratories. The number of
employees in these laboratories was 520 in the beginning of the period
and 680 at its end.

3. In a mass screening of 1000 65-year old men, 100 were found to have
a certain disease. During the following 10-year period, another 50
contracted this disease.

4. To enable early discovery and treatment of cervical cancer, regular

gynecological check-up was made of those who were found not to
have the disease at the initial examination period. The follow-up
covered 338,294 person-years at the risk and resulted in the
identification of 123 new cases of “carcinoma in situ”
EXERCISE IV

Suppose that in Populations A and B with sizes of 1,000,000 and 3,000,000,

respectively, the total number of deaths were distributed according to cause
as follows:

Cause Population Population

A B
Disease of the Heart 750 3098
Pneumonias 644 2201
Disease of the Vascular 552 1688
System
Malignant Neoplasms 366 1252
Tuberculosis 1354
357
Accidents 173 401
Chronic Obstructive 145 355
Pulmonary
Diseases and Allied
Conditions
Other Diseases of the 108 264
Respiratory
System
Diarrheal Diseases 105 240
Septicemia 88 189
Other Causes 1562 5214
Total number of deaths 4850 16256

Compute for the following for the:

a. Crude death rate

b. Cause-specific death rate for all the diseases
c. Proportionate mortality rate for all the diseases