Disease Occurance

Acknowledgments
APTR wishes to acknowledge the following individuals
that developed this module:

• Kristina Simeonsson, MD, MSPH

Department of Public Health
Brody School of Medicine at East Carolina University

• Jeffrey Bethel, PhD

Department of Public Health
Brody School of Medicine at East Carolina University
This education module is made possible through the Centers for Disease Control and Prevention (CDC) and the
Association for Prevention Teaching and Research (APTR) Cooperative Agreement, No. 5U50CD300860. The module
represents the opinions of the author(s) and does not necessarily represent the views of the Centers for Disease
Control and Prevention or the Association for Prevention Teaching and Research.
 Presentation Objectives
• Define epidemiology and recognize some of its uses
• Interpret distribution of disease according to person,
place, and time
• Calculate measures of disease occurrence and
severity
 What is epidemiology, really?
• Study of health and disease among populations

• Basic science of public health

– What causes disease?
– How does disease spread?
– What prevents disease?
– How to control disease?
 Uses of Epidemiology
• Identify etiology and risk factors

• Determine the extent of disease in a population

• Study natural history and prognosis

• Evaluate existing and new preventive and therapeutic

measures/modes of healthcare delivery

• Provide foundation for developing public policy and

regulatory decisions
 Epidemiology
• The study of the distribution and determinants of
diseases or other health-related outcomes in
populations and the application of this study to
control health problems
 Distribution of Disease
• Analysis of disease patterns
– Person
– Place
– Time
Acute Hepatitis B
Person

Source: National Notifiable Diseases Surveillance System, 2006.

 Acute Hepatitis B
Place
Incidence of acute hepatitis B, by county—United States, 2007

Source: National Notifiable Diseases Surveillance System, 2007.

Acute Hepatitis B
Time
 Measures of Morbidity and
Mortality
• Counts
• Proportions
– Prevalence
• Rates
– Incidence
– Attack rate
– Mortality rate
– Case fatality rate
– Infant mortality rate
 Counts
• Measure of disease frequency
• Number of cases or other health outcome being
studied
 Cholera
Number of reported cases, 2008

CDC, MMWR Summary of Notifiable Diseases, US 2008

 Prevalence
• Answers the question: How common is it?
– Burden of disease in a population
• A slice through the population at a point in time at
which it is determined who has the disease and who
does not
• Often stated as a percentage (i.e. per 100)
 Prevalence

# of cases of a disease present in the population

at a specified time

# of persons in the population

at that specified time
 Prevalence
• Don’t know when disease developed or the duration
• Numerator is a mix of people with different
durations of disease
– Do not have a measure of risk
• Prevalence is appropriate measure of the burden of a
relatively stable chronic condition
– Diabetes
– Hypertension
• Useful for allocating health resources
Obesity Trends*Among US Adults
(*BMI≥30, or about 30 lbs. overweight for 5’4” person)
1990 1999

2009

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

CDC, BRFSS, 1990, 1999, 2009

 Age-adjusted Percentage of U.S.
Adults who had Diagnosed Diabetes
1994 1999

2009

CDC’s Division of Diabetes Translation. National Diabetes

Surveillance System
 Incidence
• Measures change from non-disease to disease
– Can provide a measure of risk

• Also known as incidence rate

• Often stated per 100,000 population per year

 Incidence

# of new cases of a disease

during a specified period of
time
Total number of people at
risk during that period of
time
 Incidence

Department of Health and Human Services, Centers for

Disease Control and Prevention, and National Cancer
Institute, 2010
 Incidence

Department of Health and Human Services, Centers for

Disease Control and Prevention, and National Cancer
Institute, 2010
 Incidence

• Monitor changes over time

• Comparisons between groups
– Age-specific rates
– Sex-specific rates
• Goal setting
– Healthy People 2020 Objectives
 Attack Rate
• Similar to incidence (rate)
• Used when nature of the disease is such that
population is observed for a short time period, often
as a result of specific exposure
– Foodborne outbreaks
• Compares the risk of disease in groups with different
exposures
 Attack Rate

# of people who ate potato salad

who developed gastroenteritis

Total # of people who ate

potato salad
 Relationship Between Incidence
and Prevalence
• Prevalence = incidence x duration of disease

• An increased prevalence may reflect

– Increased risk of disease in the population
• Increased incidence
– Increased duration of illness
• Fewer deaths from the disease (increased survival)
• Fewer responses to treatment
 Relationship Between Incidence
and Prevalence
• An increased prevalence may reflect
– Increased risk of disease in the population
• Increased incidence

• An increased prevalence may also reflect

– Increased duration of illness
• Fewer deaths from the disease (increased
survival)
• Fewer responses to treatment
Relationship between Incidence and
Prevalence
Relationship between Incidence and
Prevalence
Relationship between Incidence and
Prevalence
Relationship between Incidence and
Prevalence
AIDS Incidence, Deaths, and
Prevalence
 Measures of Mortality
• Mortality Rate
• Case Fatality Rate
• Infant Mortality Rate
 Mortality Rate

# of all deaths in one year

# persons in the population at

midyear
 Case Fatality Rate

# of persons dying during a specified

period after disease onset or
diagnosis

Total # of people with the

specified disease
Case Fatality Rate for Avian
Influenza A/H5N1

309 deaths from H5N1

CFR 59%
522 cases of H5N1

WHO website, accessed 2/25/2011

Mortality Rate versus Case Fatality
Rate
Rabies

Measles

TB

0% 20% 40% 60% 80% 100%

Inapparent Mild Moderate Severe Fatal

Mausner & Kramer, 1985

National Cancer Institute; A Snapshot of Pancreatic Cancer
 Infant Mortality Rate

# of deaths under one year of age during

a specified time interval

# of live births reported during the

same time period

Expressed per 1,000

 Summary
• Epidemiology is the basic science of public health

• Count, describe, divide, compare

– Must use rates to compare groups and assess risk

• Primary measures of disease occurrence

– Incidence
– Prevalence
• Primary measure of disease severity
– Case fatality rate
 Collaborating Institutions
• Center for Public Health Continuing Education
University at Albany School of Public Health

• Department of Community & Family Medicine

Duke University School of Medicine
 Advisory Committee
Mike Barry, CAE
Lorrie Basnight, MD
Nancy Bennett, MD, MS
Ruth Gaare Bernheim, JD, MPH
Amber Berrian, MPH
James Cawley, MPH, PA-C
Jack Dillenberg, DDS, MPH
Kristine Gebbie, RN, DrPH
Asim Jani, MD, MPH, FACP
Denise Koo, MD, MPH
Suzanne Lazorick, MD, MPH
Rika Maeshiro, MD, MPH
Dan Mareck, MD
Steve McCurdy, MD, MPH
Susan M. Meyer, PhD
Sallie Rixey, MD, MEd
Nawraz Shawir, MBBS
 APTR
• Sharon Hull, MD, MPH
President

• Allison L. Lewis
Executive Director

• O. Kent Nordvig, MEd

Project Representative