MEASUREMENT OF

MORBIDITY

DR. SUDHIR KUMAR JHA

MBBS, MD (GOLD MEDALIST)
ASSISTANT PROFESSOR
SSR MEDICAL COLLEGE
Measurements in Epidemiology
• We can Measure:

Mortality
Morbidity
Disability
Presence, absence of attributes of disease
Health care facilities and its utilization
Demographic variables
Tools of measurement & Measuring
the Morbidity of Disease
• Lord Kelvin, an engineer, mathematician and physicist (1824-1907) wrote:
“knowledge of science begins when one can measure what he is speaking about
and express it in numbers.”
•To examine the problem of disease in human population we need to measure
the frequency both of:
(i) Disease occurrence (Morbidity) and
(ii) Mortality from the disease
•However, simply number of events has no meaning.
•Tools of measurement in epidemiology: Rates, Proportions and Ratios
Tools of measurement: Rates, Ratio and Proportion (Algorithm for
distinguishing Rates, Ratios and Proportion)
Ratio
(obtained by dividing one number by another)

Is numerator included in denominator

Yes No

Is time included in calculation

Yes No
Rate Proportion Ratio
Incidence Rate Prevalence Rate MMR
 Rate, Ratio and Proportion

RATE: Measures the occurrence of some particular event in a population during a time
period
No of deaths in one year X
1000
• Death Rate= Mid - year population

• It is a state of rapidity of developing a condition

• May be used to indicate the change in the event over a time period
• The elements: Numerator, Denominator, Time specification and Multiplier (also called base)
• Multiplier selected as per convenience to avoid fractions
RATIO:
• It expresses the relation in size between two random quantities.
• Numerator not a component of denominator.
• Numerator and Denominator expressed in the form or X:Y or X/Y
e.g: ratio of WBC to RBC; Sex ratio; doctor-population ratio; Risk –ratio; doctor-
nurse ratio.
PROPORTION: It is a ratio which indicates the relation in magnitude of a part to the
whole.
• Numerator a part of denominator
• It has no unit and is dimensionless quantity.
• Usually expressed as %.
e.g. Death due to TB/Total deaths x 100 (Proportion of TB death to total deaths)
 Rates vs Proportion

• Rates tell us how fast the disease (an event) is occurring

and

• Proporti on tells us what fracti on of the populati on is

aff ected.
 Concept of Numerator and Denominator
• Numerator: Number of times an event has occurred in a population during a specified period of time.
• Denominator: An appropriate denominator required while calculating Rate.
(a) Related to population:
i. Mid - Year population (1st July)
ii. Population at risk: focuses on groups at risk of disease. The term applied to all those who are
capable of acquiring the disease/condition in question.
e.g. For accidents--- entire city
For food poisoning---- Those who consumed food
Measles------ under-fives (or 1-3 years)
iii. Person – time concept: In Cohort studies person may enter the study at different times and may
drop out as well: person-years; person-months; person-weeks; man-hours.
(b) Related to total events: IMR and CFR (case fatality ratio), deaths per 1000 accidents
Measuring the occurrence (Morbidity) of disease
What to measure in Morbidity?

• Frequency (Incidence & Prevalence rates)

• Duration
• Severity
 INCIDENCE
• Incidence rate(IR): The number of NEW cases of a disease that occur during a specified period
of time in a population at risk for developing the disease

• Incidence Rate (per 1000 population) = (No. of new cases during a specified period/ No. of
persons at risk ) X 1000

• Numerator, a measure of new events i.e. transition from ‘no disease’ to a ‘disease’ state.
• Measure of risk in any population group such as particular age group, gender, occupational
group.
• For an IR to be meaningful, any individual included in the denominator must have potential
to become the part of group in the numerator. e.g. denominator must include only women
for calculating incidence of uterine cancer.
 Issue of time in denominator

• IR must specify time.

• Incidence measures two types of population denominator in relation to time:

(i) All the people at risk observed throughout a defined time period; or

(ii) When all people are not observed for the full defined time period,
Cumulative Incidence: If all the individuals followed up for the entire
specified period, it is known as ‘Cumulative Incidence’.

It is a measure of risk ( Incidence Risk)

All the individuals in the denominator are considered to be at risk

for the entire period of time (specified time)

The choice of time period is arbitrary: week, month, year etc.

Incidence rate (Incidence density): When different individuals are followed up
for different length of time.

Also called ‘Force of morbidity’- Rapidity of development of disease.

Denominator consists of the sum of the different times each individual was at
risk and expressed in ‘Person-time’ (e.g. In Contraceptives failure rate).

Occasionally time may be implicit in the event. e.g. Food-borne disease

outbreak (within a few hours to a few days)
• If natural H/O disease does not specify time frame- it should be
explicitly stated.

• How to Identifying New Cases in Order to Calculate Incidence rate?

 Screen a population, identify those who do not have disease and

follow for a specific period to see the development of disease.
Special Incidence Rates
• Attack rate (case rate), Secondary attack rate, Hospital admission rate etc.
Attack Rate:

• Occasionally, time associated with the denominator may be specified implicitly rather than
explicitly.
• It is used only when the population is exposed to risk for a limited period of time such as
during an outbreak/ epidemic. E.g: Food-borne disease outbreak
• It is calculated as: (No. of new cases of a specified disease during a specified time interval/
Total population at risk during the same interval) x 100
• Attack rate is not truly a rate but a proportion.
•A food-borne attack rate actually tells us the proportion of all people who ate a certain food
who became ill.
Secondary Attack Rate (SAR)
• It is defined as the number of exposed persons developing the disease within the range of
incubation period following exposure to a primary case.

USES OF INCIDENCE RATE(IR):

• The IR, as a health status indicator, is useful for taking action:
(a) to control disease, and
(b) for research aetiology and pathogenesis, distribution of diseases, and efficacy of
preventive and therapeutic measures
• For instance, if the IR is increasing, it might indicate failure or ineffectiveness of the current
control programmes.
 Prevalence

• Number of diseased persons, old and new, present in the population at a specified
time divided by the number of persons at that time. (what proportion of the
population is affected by the disease at that time? e.g. No. of individuals with
arthritis.
• We do not take into account the duration of the disease
• It is not a measure of risk.
• Prevalence is of two types:
a) Point prevalence :
 No. of people with disease at any particular point of time
 Viewed as slice through population
b) Period prevalence :
 No. of people who have had the disease at any time during a certain specified period like a
calendar year.
• e.g.- Interview Studies of Asthma
Interview Question Type of measure

“Do you currently have asthma?” Point prevalence

“Have you had asthma during the Period prevalence

last [n] years?”
“Have you ever had asthma?” Cumulative incidence
Example of incidence and prevalence
 Characteristics of Risk, Prevalence and Incidence Rate
Characteristic Risk Prevalence Incidence Rate

What is Measured Probability of Disease % of people with Rapidity of disease

disease occurrence

Units None None Cases/person-time

Time of disease Newly diagnosed cases Existing cases Newly diagnosed

diagnosis cases

Synonym Cumulative Incidence - Incidence density

 Relationship between Incidence and
Prevalence

• Prevalence = Incidence X mean duration of illness (P= I x D)

(If in the population, IR and duration of disease is not changing)

• More the duration, higher the Prevalence

 Hypothetical Example of Diabetes Screening
Prevalence, Incidence, and Duration(P= Ix D)

Screened Point Prevalence Duration Incidence(Occurance /

Population per 1,000 (yrs) yr)

Hitown (1000) 100 25 4

Lotown (1000) 60 3 20
Relation between Incidence and
Prevalence
• The word Prevalence without a ‘modifier’ (time period) is Point Prevalence.
• Addition of new cases/detection of hidden cases will increase prevalence.
• Death or Cure reduce the point prevalence. e.g. Introduction of insulin increased the
prevalence of diabetes
• A drug that increase the survival will increase prevalence.
• It means a successful programme may increase the prevalence. → a paradox in
public health
• Prevalence is not a measure of risk but measures the burden of the disease
• Valuable for planning health services
Factors Influencing Prevalence rate
1. Incidence rate
2. Cure rate
3. Death rate
4. Duration of disease
5. Control of incurable chronic diseases and resulting in longevity
(duration of disease)
6. Early detection by modern diagnostic tools
Uses of Prevalence
• Prevalence helps to estimate the magnitude of health/disease problems in the
community, and identify potential high-risk populations.
• Prevalence rates are especially useful for administrative and planning purposes,
e.g., hospital beds, manpower needs, rehabilitation facilities, etc.
• When we use prevalence, we also want to make future projections and
anticipate the changes that are likely to take place in the disease burden.
• However, if we want to look at the cause, or aetiology of disease, we must
explore the relationship between an exposure and the risk of diseases, and to do
this, we need data on Incidence.
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