Basic Epidemiology

by

Dr. Priyanka Dixit

SHSS,TISS
 Person Years
• A Person-year is: one year lived by one person.

• An individual can contribute from 0 to 1 person-years

during one calendar year.

• The total person years lived by a population is sum of

the length of time that each person has been
exposed.

• Person-Years are not directly observed; must be

calculated.
Contd…

• For example, 100 people studied for one year, or 50

people studied for two years, are both equivalent to
100 person years of observation:

1. 100 people × 1 year = 100 person years

2. 50 people × 2 years = 100 person years

Contd…

• For example, 200 people studied for one

year, or 50 people studied for two years,
CALCULATE TOTAL person years of
observation?
Contd…

• For example, let us assume that there

were 200 people in a study that
continued for five years. Of these, 185
remained until the end of the study, but
the other 15 dropped out after only 3
years. Calculate total person years?
 Why Person Years is Important?
Demographic rates are occurrence/exposure rates.
A demographic RATE relates the number of occurrences
of an event to the size of the population that produces
the events.

The number of events occurring within a population is

affected by:
(i) The total size of the population, how many people
there are at risk of the event.
(ii) The duration of time over which the individuals in the
population are exposed to the risk of the event.

An occurrence/exposure rate therefore takes into

account both dimensions the risk of occurrence:
population size and time.
 Number of Occurrences
Rate 
Person-years of Exposure to the Risk of Occurence

The numerator is a count of the number of events.

The denominator is a count of the number of person-
years exposed to the risk of the event in the population.

Both the count of events and the person-years refer to a

specified period of time (a duration with a start or stop
date/time).
 1stJan 1st March. 1stJuly 1st Nov. 31stDec.
1996 1996 1996 1996 1996

 
 
 

Total Persons=5
• Calculate CDR for 1996 using
1. Mid-year population
2. Person years lived
 1stJan 1st March. 1stJuly 1st Oct 31stDec.
1996 1996 1996 1996 1996

 
 
 

Total Persons=5
• Calculate CDR for 1996 using
1. Mid-year population
2. Person years lived
 1stJan 1st March. 1stJuly 1st Sept. 31stDec.
1996 1996 1996 1996 1 st Nov 1996

 
 
 

Total Persons=7
• Calculate CDR for 1996 using
1. Mid-year population
2. Person years lived
 Use of Person Years

1. In prospective studies

2. As mentioned in the above example, when individuals are

entering and leaving studies at different times, that is, when a
number of persons are exposed to the same risk at various
time periods.
 Assumptions involved in using Person Years

• The probability of risk must be constant in the entire study

period.

• Those who drop out will have the same level of pathology as
those who remain and complete study.
• Calculate total person- time of observation.
 Measures of Morbidity
• Disease, illness, injury, disorders, and sickness are all
categorized under the single term morbidity.

• Any disturbance in the function or structure of one’s body is

considered a disease.

• Morbidity is also any deviation from a state of health and

well-being.

• Morbidity is the extent of illness, injury, or disability in a

defined population.
Contd…

• Any disturbance in the function or structure of one’s body is

considered a disease.

• Three key morbidity rates are used in epidemiology.

(i) Incidence (ii) prevalence (iii) attack rates

 Incidence
• The term incidence is sometimes used interchangeably with
incidence rates.

• Incidence is the number of new cases of a disease which

came into existence within a certain period of time per
specified unit of population.

• Another way, it is the number of new cases of a disease

occurring in a specific population in a specified time period.
Contd…

• Incidence rate=
Number of new cases of a disease within a population in a
given time period
Number of persons exposed to risk of developing the disease
in the same time period
 Some important issues related to Incidence

• Numerator

• Issues:
– Time period (Short)
– An individual may be victim of more than one disease
within the same time period
Contd…
Solution:
1. Solution of first point: Time period should be of enough
length to assure stability of the numerator. This period of
time must be long enough to capture the condition, especially
in the case of a rare diseases or diseases with a low rate of
diagnosis.

2. Solution of second point: Calculate more than one type of

incidence rate with the same set of data and each rate
represents a different picture of the data.
Contd…

• Denominator
Issues:
– Population should be at risk.
• (a) Those who have already had the disease (if they are no
longer susceptible).
• Those who are already immunized.

• What should we do with transient population in a larger

community? For example, some people may come into risk at
the end of a study period, while other people are removed
from risk shortly after the defined period starts.
Contd…

• Solution

– Solution of first point: It is always better that population

not at risk should be excluded from denominator but if the
size of population is very large, no need to correct data.

– Solution of the second point is that: For example, if the

incidence study was a one-year study based on the regular
calendar year, the population at risk would be determined
as it existed on July 1st.
Another problem of the Denominator: Fig.1
Contd…

• Calculate incidence using

– No. of individuals in the denominator
– No. of person-years in the denominator
• Figure 1, above, shows 5 people, 2 of whom developed HIV in
the five-year follow-up period of the study.
• The cumulative incidence of HIV would thus be:
• Cumulative incidence = 2 cases/5 individuals over a 5-year
period
= 0.4 over a 5 year period
= 0.08 over a 1 year period
= 8 per 100 over a 1 year period
Contd…
• However, this measure of the development of HIV is
misleading as it does not reflect the fact that only 1 of
the 5 individuals (subject C) was in fact observed for the
entire follow-up period. Subject A was observed for only
2 years before being lost to follow-up, while subjects B,
D and E were followed for 3.0, 4.0, and 2.5 years
respectively. The total time at risk for this population of
five subjects, observed by adding their individual times,
would be 16.5 person years.
• Incidence density would be calculated as follows:
• Incidence density = 2 cases/16.5 person years
= 12.1/100 person years of observation
• Which one is better in this situation?
• Incidence density is therefore a more accurate measure
of the rate at which new infections are occurring (Why?)
There are two different ways to describe the rate at which new
infections are occurring.
 Cumulative Incidence

• The incidence rate can be described as the number of people

who become infected during a specified period of time as a
proportion of a specific population at risk of the disease. This
is called cumulative incidence.
Contd…
• In a hypothetical example, among 60 people attending a 12-
month residential detoxification program in Edmonton, 50
tested HIV negative at the start of the program in January
1998. At the end of the program in December 1998, 3 of the
50 participants tested positive for HIV. This results in a
cumulative incidence of HIV among attendees of the detox
program of 3 per 50 participants or 6% (3/50 × 100) during
this 12-month period.

• It is important to pay attention to the time period to which

the cumulative incidence relates. A cumulative incidence of
6% among attendees of a detox program would be viewed
very differently if it referred to a three-month period or a
three-year program period.
 Incidence Density

• Unlike participants in a residential program who can be

followed for the specified time period of the study, most
participants in cohort studies enter the study over a period of
time, often over several years.
• Others will become lost to contact during the follow-up
period so that their information is not available at the end of
the study.
• The length of time of the study or follow-up will therefore
not be the same for each participant.
Contd…

• Incidence rate can therefore also describe the proportion of

people who become infected during a specified period of
time as the proportion of the total time at which individuals in
a population are at risk.

• You may sometimes see this way of calculating the number of

people who become infected with a specific disease written
as incidence density.
Contd…

• Incidence density accounts for the varying time periods of

follow up. Incidence density is therefore a more precise
estimate of the rate of occurrence of a particular disease.
Contd…

• Although the numerator is the same as in the calculation of

cumulative incidence, the denominator 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 .
Difference between Cumulative Incidence (CI) and Incidence
Density (ID)

– Both the concepts of ID and CI apply to cohort studies

(Design).

• However, there are two types of cohort: Open cohort and

Closed cohort.

• Open cohort: Individuals can enter and quit (losses to follow-

up) at different times and remain for different time periods in
the study.
 Open Cohort

• A useful model for the open cohort is that of a disco. Let us

suppose an observer whose task is to evaluate cigarette
smoking during a given period of time.

• Individuals enter and quit (losses to follow-up) the disco at

different times and remain in the disco for different time
periods during which they smoke.
 Closed Cohort
A closed cohort, on the other hand, allows losses to follow-up
only. And, in contradistinction with the open cohort in which
individuals enter and quit at any time, the closed cohort
defines itself by the group of individuals present at the outset
of the observation period and, accordingly, allows losses to
follow-up only.
Contd…

• Example: An appropriate model of the closed-cohort design

would be a party where all guests arrive at the same time
while some leave the group during the evening with no
attempt to comeback later on. An observer that would be
present from the start might be interested in providing an
estimate of the frequency of smokers.
Contd…

• It is clear from the above definition that DI represents an

intensity/density (or force) as the number of incident events
is reported to a sum of time periods (rather than to persons
as such) acting as an individual time period. The ratio of the
numerator to the denominator thus acts as a measure of the
«concentration» of observed events (density) by individual
and time period.
• Therefore, if one counts 250 cigarettes smoked by 100
individuals in the disco in the course of one hour, this is
equivalent to say that one individual has smoked the 250-
cigarette during 100 hours.
• Or, in other words, that one person smokes a mean of 2.5
cigarettes per hour. Clearly, this is a speed. It can also be
viewed as force acting on the average individual.
Contd…
• In a different context, when one asserts that the number of yearly
cancer cases is equal to 250 (new diagnoses) in an at-risk
population of 100,000, one stresses the fact that the (cancer) risk
factors operate on an individual with a force of 0.00250 per year.
• ID thus has no relation to individuals as such, and does not measure
the frequency of diseased individuals.
• The interest rate represents the force with which a given capital
grows in the course of a time period. The interest rate does not
specify the amount of money earned, only the force that operates
on the capital. The interest rate also shows that the fundamental
dimension of the rate is the time without which the rate is
meaningless.
• To sum up, ID is a measure of speed, force, density, intensity, and is
a property of the inducing factor of the observed event.
• ID measures the intensity of cigarette smoking in the disco while CI
measures the frequency of smokers in a party.
• Both concepts would measure different dimensions of the same
reality.
 PREVALENCE

• Prevalence means all. It includes both old as

well as new cases.
• Two types of prevalence:
• Period prevalence
• Point prevalence
 Period Prevalence
• Period prevalence includes the total individuals who have had
the disease at any time during the specified time period.
• All persons with the disease that have carried over from the
previous time period or have become ill at the end of the time
period are included.
• Prevalence means the total number of health-related states
or events that exist in a specified population at a particular
point in time, regardless of when these began or how long
they have existed.
• However, the term "period prevalence" (e.g., annual
prevalence) is used to describe states or events that have
occurred at some time during a designated period (e.g., a
year). Annual prevalence is the total persons with a condition,
problem, and disease at any given time throughout a given
year.
Contd…

• The term "lifetime prevalence" is a useful way to express

the concept of the total number of people (or the
proportion of all people) who get a particular condition,
such as diabetes or breast cancer, during the course of
an average lifetime.
• Or we can say, lifetime prevalence is the total number of
individuals that have had a condition, problem or disease
throughout their life, or at least for a major part of it.
Lifetime prevalence is considered a form of period
prevalence.
Contd…
• Period prevalence rate =
No. of existing cases (old and new) of the disease within a time
period *1000
Estimated mid-interval population at risk
 Point Prevalence

• Point prevalence is the number of cases of individuals with a

disease, condition, or illness at a single specific point in time -
the number of existing cases at a point in time.

• Point prevalence measures the presence of a disease or

condition on a single short-time point, theoretically stopping
the clock for a minute, hour or a day and counting the existing
cases of the disease.
• Point prevalence rate=
No. of existing cases (old and new) of the disease at a point in time

*1000
Estimated population at the same point in time
 Disease Recurrence in Period Prevalence

• The epidemiologist should define any unclear issues and so state them.
• For example, if the epidemiologist decides to include all recurrences
from the previous six months in period prevalence, he or she should
make a statement in the tables and narrative of the report.

• Recurrences during a succeeding time period (usually one year) are

included.

• Some time the nature of the disease lends itself to recurrence, then
make a statement to this effect and would count it as a new case in
period prevalence. For example, the chance of a recurrence of a case of
measles is small. On the other hand gonorrhea could be a recurrence or a
current case.

• Another factor to consider in recurrences is time. If a significant amount

of time had passed from the end of the course of the disease to the
onset of the recurrent case, then it could be counted as a new case.
 Factors affecting prevalence
• As new cases arise incidence goes up. As incidence goes up
prevalence goes up.
The duration of the disease affects prevalence. When a disease has
a long duration, prevalence remains higher longer.
Intervention and treatment have effects on prevalence. As
treatment reduces cases, duration of the disease and number of
cases go down, prevalence goes down.

• Prevalence is controlled by three elements,

• The no. of individuals who have been diseased in the past.
• Length or duration of the illness.
• Incidence.

• When duration decreases significantly, prevalence can decrease

despite an increase in incidence.

• Prevalence can be measured by a single study or survey.

 Relationship between Incidence and Prevalence

Cancer of the Adult onset Roseola Essential

pancreas diabetes infantum hypertension
Incidence low Incidence low Incidence Incidence high
high
Duration short Duration long Duration short Duration long

Prevalence Prevalence Prevalence Prevalence high

low high low
Contd…

• In ideal circumstances where incidence and duration

remained constant over time, the relationship between
incidence and prevalence can be expressed as:
• P=I*D
•  Use of prevalence
• In planning community and public health services and
medical services and are used in projecting medical care
and need for hospital beds.
 Attack Rate

• Attack rate is the number of people who get sick divided by

the total number of people exposed or unexposed x 100%
– # of sick people/ total people exposed x 100%
or
– # of sick people/ total people unexposed x 100%
Contd…

• Epidemiologists use similar calculations to find out what

things might cause people to get sick.

• Epidemiologists would look at each food someone ate and

determine the food specific attack rate.
Contd…
• To calculate a food specific attack rate:
– Number of people who ate a particular food and got sick
Total number of people who ate that particular food
x 100%

Example - # of people who ate fish and got sick

Total # of people who ate fish
x 100%
 a= # of people who ate the food and got sick
b= # of people who ate the food and did not get sick
c= # of people who did not eat the food and got sick
d= # of people who did not eat the food and did not get sick

Sick Well Total Attack Rate

Food a b a+b a/(a+b) x
100%
Did not eat c d c+d c/(c+d) x
food 100%
 Sick Well Total Attack Rate
Food Fish 7 3 10 7/10=70%
Did not Did not 11 7 18 11/18=61%
eat food eat fish
 Attack Rate Ratio

• Epidemiologists can look at a ratio of attack rates

– Example:
Attack rate % for sick students who ate fish
Attack rate % for sick students who did not eat fish

70%/61% = 1.14