EPIDEMIOLOGY & PUBLIC HEALTH

CHAPTER TWO
Measuring Health & Disease

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 Definitions of Health & Disease
- Health & Disease are difficult to define precisely because
they are closely interrelated with each other.

- The World Health Organization (WHO) define health as: “

health is a state of complete physical, mental, social well-
being & not merely the absence of disease or infirmity”.

- People criticized this definition because of difficulty in

defining & measuring well-being.
- Freud define health as ” the ability to love & work”

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- Scientists have to find more practical definitions of
health & disease & to measure the health status of large
number of people.

- Definitions of health states used by epidemiologists tend

to be simple such as:
“dead or alive”, or
“disease present or disease absent”.

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Diagnosis:
- Diagnose means: to identify or recognize a disease.

- Diagnosis in medicine is defined as:

" determination of the nature of a cause of a disease by
using technical procedures".

- Diagnosis labels must be defined consistently to carry

out studies:
- on causation,
- the effectiveness of treatment & prognosis

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Reaching a diagnosis usually uses information on:
1. Symptoms: any indication of disease perceived by the
patient. Like :
Headache, pain, stomachache & nauseas
2. Signs: any objective evidence of disease or dysfunction.
Like:
Pale skin & eyes, dermatitis, & blood in urine.

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3. Test results: These tests could be done at medical
laboratories, radiological units or physical examination
units.
For examples:
- Hepatitis identified by the presence of antigens and
antibodies in the blood.
- Asbestosis can be detected by:
- signs & symptoms of lung function changes,
- signs of fibrosis of the lung tissue or
- pleural thickening or
- history of exposure to asbestos fibers.

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Problems in reaching diagnosis:
- Many diseases are complex and a group of
diagnostic criteria are needed to decide whether a
person with some symptoms or signs has a
disease.

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Changing criteria for disease diagnosis:
- Criteria for disease diagnosis may change.

- Example: The WHO modified the criteria for

myocardial infraction by using an objective
method for assessing electrocardiograms (ECG)
called the “ Minnesota Code”.
- The code based on three things:
1- the first & most important is a classical history.

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2- the release of enzymes from the damaged heart
muscle.

3- changes to the electrical field that co-ordinates

the normal heart beat, seen as abnormalities to the
ECG.

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Diagnostic criteria for epidemiology:
1- easy to use
2- easy to measure in a standard manner.
3- easy to measure under a wide variety of
circumstances.
4- easy to measure by different people.
5- produce the same result if used twice by the same
person.

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Measures of disease frequency:
Measures of disease frequency:
- Measuring disease frequency (‫)وتيرة‬
(occurrence) is an important part of
epidemiology.
- There are several measures of disease frequency
based on two important ideas:
1- Prevalence
2- Incidence. .

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- Use of rates:
- A rate is a simple idea, which can be used in
different ways.

- The commonest rate used in daily life is the

percentage. This is the number in question divided
by (per) one hundred (cent).

- Rates may be out of any number not just out of

100, e.g. based per 1000, per 100 000, per million.

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- The bottom figure called denominator so the
rate is the whole number.
- The number on the top = occurrences is called
the numerator.
- The different measures of frequency depend on
precise estimates of the denominators, represents
the population on which the calculation is based
which should include only the people who are
susceptible to the disease.
- Example: men not included when we calculate
the occurrence of cervical cancer
- Denominator = ‫ المقام‬numerator = ‫البسط‬
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Examples of numerators & denominators
Denominator Numerator Example

Live births Deaths in infants Infant mortality

during the year aged 1 year & rate
under

Females of all Deaths from breast Deaths from

ages cancer in women breast cancer
(rare in men)

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Population at risk:
Part of the total population that is susceptible
to the disease.
- We can identify the population at risk by :
1. Demographic measures:
- like age, sex, marital state, or where people
live.
2. Environmental factors
- like temperature, animal or plant life, or
presence of pollutants.

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Examples:
1- occupational injuries only occur among
working people, in this case the population at
risk is the work force.

2- Brucellosis occurs mainly among people

handling infected animals.
- The appropriate population at risk in this
instance should be farm, slaughterhouse
workers and veteranians (vets).

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 :Prevalence and Incidence
Any case of disease can either be:
- an existing case, someone that has had the

disease for sometime = prevalence

- or a new case, someone that has just get a disease =

incidence

- Prevalence & incidence are two ways of measuring

disease occurrence.

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 Rates: 1. Incidence rate
• Incidence (rate): measures occurance of disease/ measure of
morbidity.
• Number of new cases of a disease that occur in a specified
period of time in a population at risk .

Usually a year, but can be wk, mth, 5 years, etc

Number of New cases
= X 1,000

Nnmber of Persons at risks

Measure of risk: nondisease to disease Can be in

10,000, 100,000,
etc..
Most common is 100,000: IR of cancer in Palestine is 113 per 100,000 individuals
Incidence of breast cancer
Woman newly diagnosed this year with
Breast cancer = 500
Population at risk (women) = 5000000
Incidence rate=
500/5000000=0.0001X100000
=10per100000
0.0001x10000=1per 10000

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 Example

Brucellosis in the Jenin city.

Number of reported cases in 2020 was 50.
Population of Jenin is 40,000.

50
X 100,000 = 125
40,000
Per 100,000
Very important

Dr. Amer Al-Jawabreh

- Sometimes measuring incidence is difficult because of
changes in the population at risk during the time over
which data was collected.

- This can be overcome by dividing the number of cases

per year by the total number-years at risk.

- In this way, people who die or move away are no

longer at risk & we can take them out of the
calculations.
- For practical reasons, population at mid year (June) is
taken for calculations

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 Rates: 2. Prevalence
Number of affected persons in population at specific
time by number of persons in population at that time
Meaure of morbidity

All cases: new and old

Proportion NOT rate

No. ALL cases in population

at specified time
= No. Persons in population at
X 1,000
that specified time

NOT measure of risk, but measure of Burden of Disease (BOD)

Dr. Amer Al-Jawabreh
 Example
Leukemia in Palestine.
Total number of cases until December 2020 was 100.
Number of reported cases in 2021 was 40
Average population of Palestine is 4,000,000.
Prevalence of leukemia in September 2021 is:
100+40
X 100,000 = 3.5
0.000035=
Still alive 4,000,000
Per 100,000

Proportion or perecntage of diseased in that time..its NOT a rate

Can you calculate IR (incidence rate) for leukemia in 2021?

- The prevalence rate is always a proportion (Not
rate) expressed as:
- “ cases per 100 population” or “ case per 1000
population”.

- Prevalence is influenced by the chance of

surviving with a disease,
- so prevalence studies do not give very strong
evidence about the cause of a disease.

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Comparison between prevalence & incidence:
- Diseases that are short-lived because:
- they are rapidly cured or
- are fatal at an early stage,

- will have low prevalence compared with their

incidence.

- Like : Avian flu

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Comparison Between prevalence & incidence:
- Diseases with:
- A low mortality & low cure rate: Leave people
with disability Like diabetes mellitus

- Will have a high prevalence compared with their

incidence.

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- Uses of prevalence:
- Prevalence is used to measure the occurrence of
conditions where the onset of disease may be
gradual like:
- maturity-onset diabetes
- rheumatoid arthritis.

- The occurrence of these diseases vary due to:

- ethnic groups and
- environmental factors.

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 :Crude and specific rates
A- Crude rates: estimations are the rates that refer to the
population as a whole. E.g Death rate
B- Specific rates: used to examine data for different
groups usually made on the basis of:
· Age
· Sex
. cause
· Social class

C-Standardized (adjusted) rates: comparing rates between pops.

E.g Compare cancer between Japan (old pop) and Palestine (Young
pop)..we have to standardize
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Changes in population:

We can measure changes in population by:

1-Death rate,
2-Birth rate,
3-Life expectancy

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 :Changes in population
1- Death rate (mortality rate):
Epidemiologists often begin the investigation of health in
a population with data on death. In most countries, people
legally required to record the fact and cause of death on a
standard certificate that includes information such as:
•Age,
•Sex,
•Birth date,
•Place of residence,
•Cause of death

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 Crude Mortality (Death) Rate
: Frequency of deaths over a period of time in a entire
population

No. Deaths from all causes in 1 year

= No. Persons in population at midyear
X 1,000
2000 died of all causes Crude
X 100,000
4,000,000 pop of Palestine Mortality rate
=

20 children <10 died of cancer

= X 100,000 Mortality rate in
5,00,000 children <10 yr in Palestine children <10 yr,
group specific
Dr. Amer Al-Jawabreh
- The main disadvantage of a crude mortality rate is that it takes no
account of the fact that the chance of dying varies according to
age, sex, race, socioeconomic class & other factors.

- It is not appropriate to use crude death rates comparing time

periods or different geographic areas.

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 Infant Mortality Rate (IMR)
: rate of death in the first year of life (0-1 yr) per 1000 live
births in a given year.

No. Deaths in age 0-1 yr

In a given year: X 1000
No. Live births

Palestine: 16.6 per 1000 live births-2016

Palestine 1948: 2.9 per

1000 live births-2016
Mortality in early childhood :
- Infant mortality rate: used to summarize healthiness or
lack of it in a community.
- It reflects the well-being & fitness of the mother &
- the society in general.

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- The infant mortality rate is used as a measure of overall
health status when comparing different countries.

- It is related to the socioeconomic status of an area or

country.

- Social elements like poverty associated with infant

mortality which is considered as the main significant
factor.

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Maternal Mortality Ratio and Rate
Frequency of female deaths while pregnant or within 42 days of
delivery in a given period (1 year) per 100,000 live births
(Ratio)
In a given year:
No. Deaths of woman while pregnant (Ratio)
X 100,000
No. Live births

Palestine: 45 per 100.000 live births-2015

Palestine 1948: 5

No. Deaths of woman while pregnant

X 100,000 (Rate)
No. Women at reproductive age (15-49)

Dr. Amer Al-Jawabreh

Rates: Other Mortality rates
Case fatality rate (CFR)

No. Deaths from a disease in 1 year

= No. Persons with the disease
X 1,000

8 died of rabies
= X 1000
10 rabies cases

Measure of sevirity of disease

- Section 2 14.4.2022
 Mortality rates-Group Specific
Frequency of deaths over a period of time in a specific group
of population (Sex, age, occupation, race)
No. Deaths in men (40-60 yr) CVD in 1 year
= No. Men (40-60 yr) at midyear
X 1,000

200 Men died of CVD

= X 100,000 Mortality rate
40,000 men-midyear-Palestine of CVD-group
specific

20 children <10 died of cancer

= X 100,000
300,000 children <10 yr in Palestine
Mortality rate in
children <10 yr,
group specific
Dr. Amer Al-Jawabreh
Life expectancy:
It is defined as ‘the average number of years we expect an
individual of a given age to live if current mortality trends
continue”.

- Life expectancy at birth attracts greater importance to

deaths in infancy than deaths later in life.

- Life expectancy at later ages may be used to examine

the impact of the environment or health services on
older people.

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Other measures of mortality in early childhood :
1- Fetal death rate: refers to the spontaneous intrauterine
death of a fetus at any time during pregnancy

2- Stillbirth rate: the death of a baby before or during

birth after 28 weeks of gestation.

3- Perinatal mortality rate: the "number of stillbirths &

deaths in the first week of life per 1,000 live births,
The perinatal period starts at 22 completed weeks (154
days) of gestation & ends seven completed days after birth
Sec 1 19.4.2022

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4- Neonatal morality rate: is the number of
neonates dying before reaching 28 days of age, per
1,000 live births in a given year.
Neonate: ‫طفل حديث الوالدة‬
Neonate: newborn infant age from 0-28 days after
delivery

5- Post-neonatal mortality rate: is the death of

children aged 29 days to one year
”.

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 :Morbidity
Morbidity is the state of being diseased.
Morbidity can be classified into three main groups:
1. impairment: it is organ based and describes failure or
loss of that organ for example in renal or cardiac
failure or the loss of a limb or eye.
2. disability: it is person based, for example if someone
is unable to work, wash themselves or catch a bus.
3. handicap: it is socially based, for example if someone
is unable to fulfill the functions of a student, a parent
or any other profession.
4. Sec. 2 /20.4.2022

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Health Indicators: standardized measures by which to
compare health status and health system performance and
characteristics.

Health Indicators are used to compare information on:

1-The overall health of the population served.
2- The major non-medical determinants of health in the
region.
3- The health services received by the region's residents.
4- Characteristics of the community or the health system.

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Health indicators include:

1- Morbidity indicators: The incidence rate of diseases, i.

e. AIDS.

2- Mortality indicators: IMR, MMR, Death rate of

diseases i. e cancer.

3- Service indicators: No. hospitals, no. hospital beds per

inhabitants
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