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Chapter 3

The Occurrence of Disease I. Disease Surveillance and Measures of

A fundamental role of public health
Can monitor changes in disease frequency and levels of risk
Most often used for infectious disease but increasingly used to
monitor changes in other types of conditions including cancer,
injuries and illnesses after natural disasters, completeness of
vaccination coverage and prevalence of drug-resistant organisms
Defined by CDC as ongoing systemic collection, analysis and
interpretation of health data essential to the planning,
implementation and evaluation of public health practice closely
integrated with the timely dissemination of these data to those
who need to know
Provides decision-makers with guidance for developing and
implementing the best strategies for programs for disease
prevention and control
Importance of standardized definitions of disease and diagnostic
Passive and Active Surveillance
Passive surveillance/reporting: available data on reportable
diseases are used, or in which disease reporting is mandated or
requested, with the responsibility for the reporting often falling
on the health care provider or district health officer
o Quality of data depends on individual or staff who may not
receive any additional funds or resources, i.e. reporting is
not their primary responsibility
o Underreporting or lack of completeness are likely
o Reporting instruments must be simple and brief
o Less expensive
Active surveillance: staff recruited to carry out a surveillance
program by making periodic field visits to health care facilities
such as clinics and hospitals to identify new cases of a disease or
deaths from the disease that have occurred (case finding)
o Involves interviewing physicians and patients, reviewing
medical records, surveying villages/towns to detect cases
o Reporting is more accurate because staff are specially
trained for the position
o More expensive

Challenge of disease surveillance using mortality data is differing

estimates of mortality
o Malaria mortality estimates vary greatly in developing
countries due to difficulties in obtaining reliable data in the
absence of a standardized surveillance system, vital
registration and diagnostic testing
Surveillance can also be used to assess changes in levels of
environmental risk factors for disease

Stages of Disease in an Individual and in a Population

Healthy->disease onset->symptoms->seek care->diagnosis>treatment->outcome: cure, control, disability, death
Sources of data: interviews, physician records, hospital records
o The data source influences the rate calculated for the
frequency of disease (i.e. hospital records dont include
people who died prior to seeking care)
Rate: how fast the disease is occurring; proportion: the fraction
of the population affected
Measures of Morbidity
Incidence rate: number of new cases of a disease during a
specific period of time in a population as risk of developing the
o Incidence rate per 1,000 = No. of new cases of a disease
occurring in the population during a specified period of
time / No. of persons who are at risk of developing the
disease during that period of time x 1000
o Incidence rate is a measure of risk
o Denominator must only include people at risk of disease
(i.e. for uterine cancer, only women are included in
o 2 types of denominators:
people at risk who are observed throughout a defined
time period
if incidence is calculated using period of time
during which all the individuals in the
population are considered at risk then it is
cumulative risk
when all people are not observed for the full time
period, person-time, or units of time when each
person is observed
person-time is the units of time that each
individual at risk was observed

Ex. 1 person at risk observed for 5 years = 5

person-years (py)
If people at risk are observed for different
periods of time, the incidence rate is: Incidence
rate per 1000 = no. of new cases of a disease
in a population during a specified time / total
person-time x 1000
o Identifying new cases in order to calculate incidence
Define and screen population for the disease at a
baseline; of those who do not have the disease,
follow-up after a period of time; of those who develop
the disease in the time period = new incident cases
Attack rate: the number of people exposed to a suspect food who
became ill divided by the number of people exposed to that food
(not a true rate, really a proportion of all people who ate a
certain food who became ill)
Prevalence: number of affected persons present in the population
at a specific time divided by the number of persons in the
population at that time (i.e. the proportion of the population
affected by the disease at that time), prevalence per 1000 = No.
of cases of a disease present in the population at a specific time /
No. of persons in the population at that specified time x 1000
o Point prevalence: prevalence of the disease at a certain
point in time
o Period prevalence: people who had the disease at any
point during a certain time period
o Incidence vs. prevalence: prevalence is a snapshot in time
of those who have disease vs, those who dont, whereas
incidence is new cases of the disease for a given
Point prevalence: Do you currently have asthma?
Period prevalence: Have you had asthma during the
last [n] years?
Cumulative incidence: Have you ever had asthma?
o Prevalence can only be lowered by death or cure, so when
insulin became available the prevalence of diabetes
increased because those who formerly would have died
now survived
o Prevalence is very important for public health planning
Problem with incidence and prevalence measurements
o Problems with numerators
Defining who has the disease
Ascertaining which persons to include in the
numerator (i.e. finding cases)

o Problems with denominators

Selective undercounting of certain groups in the
Deciding who to include in denominator (i.e. should
women with hysterectomies be included in the
denominator for uterine cancer?)
o Problems with hospital data
Hospital admissions are selected
Records designed for patient care not research
Defining denominators is difficult because most
hospitals do not have defined catchment areas
Relationship between incidence and prevalence
o Prevalence = incidence x duration of disease
o Spot map: does not take population density into

o Important role of epidemiology is surveillance of disease and
surveillance of morbidity in planning and development of health
o Different approaches to measuring morbidity