Measurement of Disease

Mortality and morbidity

measurements

Prof. Mohamed Salah

 Presentation plan
• Importance of Measurement of Disease

• Mortality measurements

• Morbidity measurements
Why we measure diseases?
1. To know the magnitude of the health
problems
2. To choose which one to start with
3. To plan for prevention
4. To evaluate the program
5. For comparison and international
classification
Measurement of the disease
• Ratio = X:Y i.e males to females

• Proportion = X / (X+Y) X K (k is a constant)

percent is an example of the proportion

• Rate = X/ x+Y X K in a certain time interval

Mortality measurements of
disease
 Mortality measurements
• Mortality Statistics is a part of a system of
vital records.

• Facts collected and presented in

numerical form and derived from records
of vital events: birth, death and
migration.

• A valid death certificate is essential for

burial of the dead body .
 Causes of Death:
• As written in the death notification, there are three
spaces for the cause of death:

1. The immediate cause,

2. Intermediate conditions
3. Underlying cause, which is the official cause of
death.
• classified according to the International Statistical
Classification of Diseases, Injuries, and Causes of
Death (ICD) revised every 10 years by the WHO.
• The last version of the ICD is the tenth.
• A nosologist is a person with experience in coding
the causes of death according to the ICD.
• Many changes have occurred
in the various revisions of ICD,
e.g., before 1948 any death
in diabetics was considered
due to diabetes,
• so after that date there was a
decline in number of deaths
due to diabetes!!!
• The sources of inaccuracies in death certificate:
1. Errors of physicians,
2. Unfamiliarity with the disease,
3. Delayed reporting of autopsy results etc.

Studies involving Death Certificate, as the

source of data concerning the cause of death
should contain validation procedures, e.g.,
checking with hospital records, autopsy results,
family physician etc.
Crude death rate (CDR) :
= Total number of deaths (all ages, both sexes & all causes)
in a population during a certain year and locality / Mid-
year population in the same year and locality X 1000
Advantages:
1- It is the most widely used descriptive measure of
the over all health of a community.
2- It requires minimum of data for the calculation of
vital rates.
3- It is simple to compute and understand.
4- It is very useful for observing the yearly or seasonal
fluctuations as well as the general trend of mortality
in the population.
Disadvantages:
1- It is too broad and non specific which calculated for the total
population irrespective of age, sex or causes.
2- It mixes many population groups whose mortality varies
widely.
3- It is influenced by the forces of mortality prevailing in a given
community and by certain characteristics of its population as
age distribution.
4- Changes in mortality from one cause may not show in the
crude death rate when it is compensated by a reverse change
in other causes.

These disadvantages can be overcome by the use of what is

called “the specific death rates”.
• Crude death rate (CDR) is the annual death
rate without any adjustments.

• It is a simple figure, easily interpreted and

requires minimum information to calculate.

• It cannot be used for comparison or evaluation

between different countries.

• Midyear population: is the number of

population at the middle of the year (June)
 Specific death rates
may be done according to
• Age and sexs pecific death rate

• Example: death rate in men with age 25-35 years and living in
Saudi arabia during 1982=
• Number of deaths in Saudi men, 25-35 y during 1982 X1000
Midyear population of Saudi men, 25-35 y1982

• The use of age and sex specific death rates can be used in
comparing mortality overtime in one place and to compare
mortality between different countries with different age and sex
composition.
• Age and death:

• During the first year of life, the person

experienced the highest mortality rate, which
drops afterwards to reach a low plateau during
the youth and early middle age.

• Mortality rates rise again in old age (the curve

is a U-shaped curve)
• Sex and mortality:

In most of the age groups males experience a

higher mortality rates from all diseases, except
for malignancies of reproductive organs and
maternal mortalities due to pregnancy, labor and
puerperium .
 Cause specific death rate
= number of deaths due to a specified cause per
1000 midyear population.
• Example: death rate from tuberculosis in Egypt
during 1982=
Number of deaths due to Tuberculosis during
1982 X1000 /
Midyear population of Egypt in 1982
 Cause specific death rate
• Cause specific death rate of a certain disease
reflects the risk of that population to die from
that disease.

• Cause specific death rate in a certain age group

and sex, e.g., death rate from cancer breast
among females aged from 55-65 y.
 Case Fatality Rate
= number of deaths per 100 of cases
'diagnosed or reported' to have a specified
condition.
 Case Fatality Rate
• Its significance

• The rate is supposed to reflect the fatality of the

disease
• It is an indicator of the availability and effectiveness of
curative measures,
but it is usually overestimated due to lack of reporting
of 'mild, nonfatal' cases.

• This rate not considered as a measure of risk of the

disease in the population .
Proportionate Mortality Rate (or Ratio)

(PMR) = number of deaths due to a specific

cause per 100 total deaths.

• Sometimes this is the only available rate to

calculate, e.g., in occupational settings.
• It cannot be used to measure the health risk of
a population for that disease.
 Proportionate Mortality Rate
A B
Population 100,000 100,000
Total deaths 300 100
CDR per 1000 3 1
Deaths from cancer 50 50
Cancer deaths per 1000 0.5 0.5
PMR for cancer 17% 50%

• But this does not mean that population B is at a higher risk of developing
cancer than population A. Actually, population B has less total deaths, i.e.,
it is healthier! compared to population A.

• In this situation, having less total deaths may account for the higher PMR
Child Health and Mortality Rates
Child Health and Mortality Rates
• Viability of the fetus is the point at which the
fetus can be supported to live outside his
mother’s uterus.
• This point depends upon the health facilities
available in the community.
• In Western communities, this point is the 20th
week of gestation, but internationally it is still
the 28th week.
• Before this point expulsion of a dead fetus is
called an abortion while after that point it is
called a still-birth.
1- Fetal death rate (Still Birth Rate)
= Number of fetal deaths x 1000
• Number of fetal deaths + live-births

• This rate is usually under-estimated. Fetal

deaths are attributed mainly to congenital
malformations.
 2- Perinatal death rate
= Number of deaths in the perinatal period x 1000
• Number of live births + Number of still birth

• The perinatal period is from point of viability (28

weeks gestation) till 7th day after birth.
• Perinatal mortality rate is under-estimated in
some countries.
• Deaths during these times reflect congenital
malformation and birth injuries.
 3- Infant mortality rate
= Number of deaths in the first year of life x 1000
Number of live births

• This is the most sensitive index for the health

status of a community and one of the indices
used to evaluate the development of a country.
• It is further subdivided into:
 3- Infant mortality rate cont.
a) Neonatal death rate
= Number of deaths in neonatal period (less than 28 days of life) x 1000
Number of live-births
• Deaths during this period are due to prematurity, congenital
malformations and birth injuries, what is usually called
biological factors.
b) Post-neonatal death rate
= Number of deaths in the post-neonatal period x 1000
Number of live births
• The post-neonatal period is (from 28th day of life to the end of
first year of life)
• Deaths during this period are mainly due to infectious diseases
and their complications, which are usually due to
environmental factors and the quality of health care.
 4- Preschool mortality rate (1-5 years)

= Number of deaths of children aged 1-5 years x 1000

Number of live births

• Deaths during this period are mainly

environmental including accidents & injuries.
 Child Mortality indices in Egypt
• Mortality indices serve as indicators of child health in
Egypt. The following data are recorded for 2014: (DHS
2014)
• 1. Infant mortality rate (IMR): 22/1000 live births
a. Neonatal mortality rate (NMR): 14/1000 live births
b. Post neonatal mortality rate (PNMR): 8 /1000 live birth

2. The under- 5 year mortality rate: 27/1000 live birth

All mortality rates have declined greatly over the past 20

years.
 Child Mortality indices in KSA
• Mortality indices in KSA. The following data are
estimated for 2016:

1. Infant mortality rate (IMR): 11.2 /1000 live births

2. The under- 5 year mortality rate: 12/1000 live birth

Maternal Mortality Ratio/Rate (MMR)
Maternal Mortality Ratio/Rate (MMR)
• Maternal mortality is defined as deaths of
mothers due to causes related to or
aggravated by pregnancy, labour and
puerperium.

• Deaths are usually more during child birth

and early puerperium. (Puerperium is the 42
days following delivery).
•
 Maternal Mortality Ratio/Rate (MMR) cont

• Maternal Mortality Ratio:

• = Deaths of women during pregnancy, labour or
puerperium in certain year x 100,000 /
Number of Live Births in the same year

Maternal Mortality Rate:

• = Deaths of women during pregnancy, labour or
puerperium in certain year x 100,000 /
Number of pregnancies in the same year
• In practice, some pregnancies are not registered and as a
result the population at risk of maternal death is generally
taken as the number of live births. The number of live births is
assumed to be a good proxy indicator of the number of pregnancies.
The main causes of maternal mortality
• Direct obstetric causes:
• Hemorrhage (antepartum, and postpartum): Bleeding
is the most important cause of maternal mortality.
• Toxemia of pregnancy
• Puerperal sepsis: may be fatal through its complications
• It is preventable by asepsis and chemoprophylaxis
• Indirect obstetric causes:
• Those resulting from previous existing disease or
disease that developed during pregnancy as
hypertension, hepatitis
2-Morbidity measurements
of disease
 Incidence Rate
• Incidence Rate: “ The number of new
(incident) cases of a disease that occur during
a specified period of time in a population at risk
of developing that disease”

= number of new cases of a disease during a specified period of time X 1000

Number of population at risk of that disease in the same time

 Incidence Rate
• A high incidence rate means a high occurrence of disease; a
low incidence rate means a low occurrence of disease.

• For incidence to be meaningful, any individual who is included

in the denominator must have the potential to get the disease
and become a part of the group counted in the numerator,
• e.g., in calculating the incidence for uterine cancer, the
denominator must include only women having uterus because
women with previous hysterectomy would not have the
potential to become part of the numerator (cases with uterine
cancer).
 Incidence Rate
• Incidence rate of disease is a
measure of Risk, i.e., the
probability of healthy people to
develop the disease during a
specific time period.
 Attack rate
• Attack rate: is expressed as a percentage. It
is an incidence rate that is calculated in an
epidemic situation using a particular population
observed for a limited period of time,

It is used in investigation of outbreak.

 Prevalence Rate
• Prevalence Rate: “ The number of diseased
(or affected) persons in a population at a
specific time divided by the number of
population at that time”
= Number of cases of with a disease present in the
population at a specified time X 1000 /
Number of population at risk at that time
 Prevalence Rate
• Point prevalence refers to a prevalence rate measured at a
specific point of time while period prevalence refers a
prevalence rate measured during a specific time period or
interval.

• Prevalence rates are influenced by both the incidence of

disease and by the duration of illness. If incidence rate is
steady, and the population is stable (no in or out migration),
prevalence = incidence X duration of disease. P = I x D

• Since prevalence rate contains all known cases of disease,

• it can be used to measure the amount of illness in a
community and subsequently to determine the health care
needs of that community or the burden of that disease.