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Basic Measurement in Epidemiology

By: Firdawek G.
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Learning objective

At the end of this session, the students will be able:

Describe tools used to quantifying health related

events

Calculate & interpret the measures of morbidity

Calculate & interpret the measures of mortality

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Contents

 Count, ratio, proportion, rates

 Measures of Morbidity/disease

 Measures of mortality/death
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 Epidemiology is mainly a quantitative discipline, so we

should quantify/measure the occurrence health related
events
Why we quantify/measure occurrence health
related events ?
1. To be familiar with its distribution and make
comparisons (to identify population at a higher risk)

2. For monitoring the health status of the population and

planning health services(appropriate intervention)
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Tools used in quantifying disease/death

frequency are:

1.Count

2.Ratio

3.Proportion

4.Rate
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1.Simple Count
 It counts health related events and expresses
as integers
 It Answers:
 how many people have this health related
events or number of cases in a defined
population
 Can be used to compare disease/death
frequency between populations iff the
population are known to be of similar size
E.g.≠of persons having COVID-19 in town A,2020?
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2.Ratio
A ratio is the relative size of two quantities or one
character divided by another
 Is expressed as : a/b or a:b or ‘a’ to ‘b’
 No specific relationship is necessary between the
numerator(a) and denominator(b)
 i.e numerator is not necessarily included in the
denominator
 Ranges from zero to infinity

Example
Women in Ethiopia who died from cervical cancer in 2020 
Women in Ethiopia who died from breast cancer in 2020
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3. Proportion
 It measures occurrence of a part of event to the
whole population
 It is a ratio in w/c numerator is included in the
denominator
 Is expressed as :a/b
 be expressed as a fraction,decimal,or percentage
 Its result ranges between 0 and 1 or (0–100%)

Example
Women in Ethiopia who died from cervical cancer in 2020 
Women in Ethiopia who died from cancer in 2020
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4.Rate
 Special form of proportions that includes a
specification of time
 Most commonly used in epidemiology because it
most clearly expresses probability or risk of disease
or other events in a defined population over a
specified period of time
 Measures speed at w/c things happen
 Rate may be expressed in any power of 10
 Values range from zero to 1
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Notice three important aspects of this formula:

1.The persons in the denominator must reflect the
population from which the cases in the numerator
arose
2.The counts in the numerator and denominator should
cover the same time period.
3.In theory, the persons in the denominator must be
“at risk” for the event
E.g. ≠of new cases of adults with AIDS in Ethiopia in 2020
Total adults in Ethiopia in 2020
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NB
All rates are ratios
All rates are proportion too
 All proportions are ratios
 But all proportions are not rates
All ratios are not proportions
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Measures of disease occurrence

Disease occurrence
1.Prevalence

A.Point Prevalence
B. Period prevalence
2. Incidence
A.Cumulative incidence/ incidence proportion
B.Incidence density/rate
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1. Prevalence (P)
 Is the measure of the proportion of persons
having a particular disease in a specific population
at a given point in time or over period of time
 Is expressed as :P=A/B

Where
A= total number of cases=new case + pre-existing case

B= total number of individuals/population

 A measure of disease status, disease burden/scope

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Types of Prevalence
1.Point prevalence
Measures number of cases that exist in a
population at a given single point in time

The amount of disease in a population usually

changes constantly

Thus, may not be useful for assessment of

diseases with short generation period
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Point prevalence
= Number of cases in the population at time t x 10n
total population at time t
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2.Period prevalence
Measures number of cases that exist in a
population during a specified period of time
( week, month, year,…)

 Used when it is difficult to know when the

disease considered present

 It combines both point prevalence and incidence

in a single parameter
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Period prevalence
=all cases (pre-existing + new) during the time period x10n

average population during the given period of time

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Example

A study starts with 5,000 people. Of these, 125

have the disease at the beginning. Over the next
one year, 75 develop the disease.

Calculate the prevalence of disease

1.at the beginning of the year

2.at the end of the year

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Solution

1.at the beginning of the year

Point prevalence=125/5000

1.at the end of the year

Period prevalence=125+75/5000
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Consider when you compare prevalence:

1.Point prevalence cannot be compared with period

prevalence

2.Prevalence may be compared among different

disease or population if the same length of time is
used
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2. Incidence
 Measures the occurrence of new events/cases
in a defined population at risk within a specified
period of time

 population at risk is persons who are potentially

susceptible the event being studied
 Can be measured as proportion/rate

 Measures probability/risk/rapidity of developing

disease/events during a period of observation
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A. Cumulative Incidence/proportion
 It measures occurrence of new cases of disease
or events in a population at risk over a
specified period of time
 It assumes that the entire population is at risk
and is followed up for specified time of period

 Population at risk is fixed and followed for the

same time

 It is an estimate of average risk

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CI
=≠of new events during a specified period of time x10n
Population at risk in the specified period of time
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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 histoplasmosis. Twelve
months later, 35 had antibodies, including the
original 25.

Calculate

1. the prevalence at the second survey, and

2. Compare the prevalence with the 1-year incidence

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1. Prevalence at the second survey:

x = antibody positive at second survey = 35
y = population = 5,000
x/y X10n = 35/5,000 x 1,000 = 7 per 1,000
2. 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
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Special type of incidence

Attack Rate
An attack rate is a variant of cumulative incidence
When to apply/use?
in a narrowly defined population
in a narrowly defined time ,such as during an
epidemic
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Attack rate
=#new cases among the population during the period ×100
Population at risk at the beginning of the period
Example

Of 100 persons who attended a weeding ceremony, 46

subsequently developed gastroenteritis .

Calculate the AR

AR =46/100*100=0.46=46%
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Secondary Attack Rate

A secondary attack rate is a measure of the
frequency of new cases of a disease among the
contacts of known cases

Secondary Attack Rate

= #cases among contacts of primary cases × 100
total number of contacts
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Example
Seven cases of hepatitis A occurred among 70
children attending a child care center. Each infected
child came from a different family. The total
number of persons in the 7 affected families was
32. One incubation period later, 5 family members
of the 7 infected children also developed hepatitis
A.
Calculate
1. the attack rate in the child care center
2. the secondary attack rate among family contacts
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Answer
1.Attack rate
cases = 7
number of children = 70
Attack rate =7/70*100=0.1=10%
2. Secondary attack rate
cases among family contacts = 5
total contacts = 32 − 7 = 25
Secondary attack rate
=5/25*100=0.2=20%
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B. Incidence density /rate

 It measures occurrence of new events over a
specified period of time in a population at risk
throughout the interval
IR =Number of new events during a period
Total person-time of exposure/sum of time periods at risk

 Denominator: the sum of each individual’s time at

risk (or time free of a disease) is counted
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Person- time
 It is a calculation combining persons and time
 It is sum of length of time period passed free of
illness (at risk) by each individual member of
study
 It accounts for the amount of exposure time of
members
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 Individuals may be exposed to the risk of an

event for varying amounts of time during a total
time period of a certain length due to:

 Entering the time period later

 Leaving the time period earlier
 Experiencing the event of interest

 It is a good measure in a dynamic cohort

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Example
1000 HIV negative persons were tested one year later
and 50 were found HIV positive.

1.What is the cumulative incidence of HIV infection?

50 cases per 1000 population are at risk or(5% are at
risk) in this year
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2.What is the incidence density of HIV infection?

Assuming disease is acquired on the midpoint of the
interval between the last disease-free visit and the
first visit when disease is diagnosed
950 persons not infected = 950 person-years
50 persons at risk for ½ year = 50 x ½ = 25 person-
years
=50 new cases/975 person-years
= 0.05 case per person-year, or 5.1 cases per 100
person-year
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Example

Investigators enrolled 2,100 men in a study and

followed them over 4 years to determine the
rate of heart disease.

We assume that persons diagnosed with disease

and those lost to follow-up were disease-free for
half of the year, and thus contribute ½ year to
the denominator
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1.Initial enrolment: 2,100 men free of disease

2.After 1 year: 2,000 disease-free, 0 with disease, 100

lost to follow-up

3.After 2 years: 1,900 disease-free, 1 with disease, 99

lost to follow-up

4.After 3 years: 1,100 disease-free, 7 with disease,

793 lost to follow-up

5.After 4 years: 700 disease-free, 8 with disease, 392

lost to follow-up
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1. Identify the cases diagnosed

2. Calculate the person-years of observation
3.Calculate person time rate
solution
1. cases diagnosed = 1 + 7 + 8 = 16
2. person-years of observation
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Or

1)700 men x 4.0 years = 2,800 person-years

2)8 + 392 = 400 menx3.5 years = 1,400 person-years

3)7 + 793 = 800 menx2.5 years = 2,000 person-years

4)1 + 99 = 100 menx1.5 years = 150 person-years

5)0 + 100 = 100 menx0.5 years = 50 person-years

Total = 6,400 person-years of observation

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Comparing Incidence & Prevalence
Incidence
 It is new cases over
period of time
 Indicate how fast the
disease happening
 Measures disease risk
 Useful for identifying risk
factors
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Prevalence
 It is all new+ pre-existing
cases at point/period of
time
 Indicate how much is the
disease there
 Measures disease burden
 Useful for planning health
services
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Relationship of Incidence to Prevalence

 Prevalence is based on both incidence (risk)
and duration of disease.
 High prevalence of a disease within a population
may reflect high risk, or it may reflect prolonged
survival without cure.
 Conversely, low prevalence may indicate low
incidence, a rapidly fatal process, or rapid
recovery
 Thus, prevalence rate is directly proportional to
both incidence rate and to the average duration
of the disease and thus expressed as
p ~ IR x D
Relationship between prevalence and incidence
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Factors influencing Prevalence

Increased By
 By longer duration of the disease
 Prolongation of life of patients without cure
 Increase in new cases
 In-migration of cases
 Out-migration of healthy people
 In-migration of susceptible people
 Improved diagnostic facilities(better reporting)
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Decreased By
 Shorter duration of the disease
 High case fatality
 Decrease in new cases
 In-migration of health people
 Out-migration of cases
 Out-migration of susceptible people
 Improved cure rate of cases
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Measures of Mortality
 Mortality is the fundamental factor in the
dynamics of population growth
 A mortality rate is a measure of the frequency
of occurrence of death in a defined population
during a specified interval

Mortality rate =
deaths occurring during a given time period × 10n
size of the population among which the deaths
occurred
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 Variety of measures of death :

1. Crude death rate

2. Specific death rate

3. Standardized/adjusted death rate

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1.Crude death rate

Rates that apply on total population/summary rate
 Is influenced by individual population characteristics
Used for International comparisons (superficial)as
being populations are not similar in all respects
Easy to calculate
 Difficult to interpret b/c of being crude
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2.Specific death rates

Rates calculated with in homogeneous subgroups
(age,sex,…)
Mortality rate limited to a particular group
Example
≠of deaths occurred among persons age 10-19yrs in 2020
total number of persons age 10-19yrs in 2020
Used for detail understanding of death among
population subsets/risk factors
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but we do not use always because:

1.The frequency of the death in the subgroup may

be unknown

2.The size of the subgroup may be unknown

3.The number of persons at risk may be too small

to provide stable estimate
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Standardized (adjusted) death rate

 Comparing mortality rates in two or more

different geographic areas is important for the
evaluation of community health status
 Crude death rates are not generally suitable to
make comparison due to population differences
in some characteristics like age , sex,… that may
influence that rate
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 Standardization helps to compare mortality rates

between groups with different characteristics

Standardized/adjusted death rate

 is a crude death rate that has been modified to
control the effect of some characteristics of
population and make fair comparison among
populations
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 Standardized death rates is calculated based on

particular characteristic(s) as standard
two methods:
1. Direct and
2. Indirect standardization

Sources of standard/Reference population

 Largest of two populations
 Combination of two populations
 Use of national/world standard population
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Direct standardization

Is applied w/n:

1.Age-specific Mortality Rates of Population (s) of

interest is Known

2.Have Standard Population

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Procedure for direct standardization

Calculate the age-specific mortality rates for each
age group in each population
Choose the standard (reference)population
Multiply the age-specific mortality rates of the
other population under study to the number of
persons in each age group of the standard
population(expected deaths)
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Procedure for direct standardization

Add the number of expected deaths from all age
groups
Finally, divide the total number of expected
deaths by the standard population gives you
adjusted mortality rates(AMR)
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What to conclude by comparing the crude death

rate of two populations?

population B ,24.57/1000,have higher death

rates than population A,17.44/1000
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Age adjusted death rate for population A

=total number of expected deaths / total standard population
= 1186.18/ 51,000 x 1000= 23.3 per 1,000
Age adjusted death rate for population B
= 1158.99/ 51,000 x 1000= 22.7 per 1,000
Comparative mortality ratio=23.3/22.7=1.03=103%
Conclusion
The risk of death is higher in population A than in
population B or
Death rate in population A is 3% more as
compared to population B
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Indirect standardization
It is performed to compare observed death in a
high risk population with expected death in
standardize population
This method is applied w/n:
1. Age-specific mortality rates of the population (s)
of interest are unknown

2.Age-specific mortality rates of the reference

population is known
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Procedure for indirect standardization

Choose a reference population

Calculate the observed number of deaths in the

population (s) of interest

Calculate the age-specific mortality rates from

the chosen reference population
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 Multiply the number of people in each age

group of the population(s) of interest by the
age-specific mortality rate in the comparable
age group of the reference population.
(to find expected death )

 Divide the total number of observed/actual

deaths of the population(s) of interest by the
expected deaths= Standardized mortality
ratio” SMR
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Example
In a population of 534,533 White male miners, 436 died
from tuberculosis (TBC) in 1950

Is this mortality experience from TBC greater than, less

than, or about the same as that which you would expect in
White males of the same ages in the general population?
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SMR =observed deaths *100

expected deaths
=436/181.09x100 =241%
Conclusion:
The risk of death is higher in White male miners
population than White males of the same ages in
the general population
White male miners have a mortality rate which
is 2.41 times that of the general White males
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Interpretation
SMR = 1
Risk is the same in both the observed population
and the reference population
SMR < 1
Risk is lower in the observed population compared
to the reference population
SMR > 1
Risk is higher in the observed population
compared to the reference population
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When to compare SMRs of different

population?
Since the number of deaths in a population
depends on age distribution
the number of observed deaths and the
calculation of the expected deaths must depend on
the age distribution of the population of interest

Consequently, SMR must also depend on the age

distribution of population of interest
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 Therefore, when using the same reference

population in the calculation of SMR, the SMR
from one population cannot be compared to
the SMR from another population unless the
two populations are similar in age distribution
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Thank you for your attention!

Any concern, question?