Me asu r es o f

Dise ase s
Fr equency(1 )

Gao Hongcai
Email: gaohc2005@163.com
School of Public Health, Jining Medical
College
Introduction
 Epidemiologists use a variety of
methods to summarize data. One
fundamental method is the frequency
distribution. The frequency distribution
is a table which displays how many
people fall into each category of a
variable such as age, income level, or
disease status.
 In later lessons you will learn about

frequency distribution (time place

people).
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 Introduction
 cases :
people who have a disease or condition
being studied are generally referred to as
cases.
 non-cases :
People without the disease are called non-
cases.

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 Introduction
 The most common form of
organizing epidemiologic information
is through collecting information
about cases and non-cases.

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 Introduction
 counting cases of disease in a
population is the unique domain of
epidemiology—it is the core
component of disease surveillance
and a critical step in investigating an
outbreak.

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 Introduction
 Case counts must be placed in proper
perspective, however, by using rates to
characterize the risk of disease for a
population. Calculating rates for different
subgroups of age, sex, exposure history
and other characteristics may identify high-
risk groups and causal factors.
 Such information is vital to the
development and targeting of effective
control and prevention measures.
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 Introduction
 The numbers are usually translated into
rates.

 Rates indicate the risk of disease for a

population.
 This helps to identify high-risk groups and
causal factors.
 Data elements collected from cases and
non-cases are called variables (age, sex,
race, weight, height, temperature, blood
pressure, disease, death etc)
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 Why measure disease?
 To quantify or measure the
occurrence of disease is fundamental
in understanding:
 Description of health events in the
population
 Impact of disease in the population
 Possible associations between factors
and disease
 Possible mechanisms of spread
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
 Rates, Ratios and
Proportions
 Variables or data elements are summarized
to provide number of cases, proportions,
rates and ratios = frequency
 In epidemiology many variables have only
two possible categories
 these are called dichotomous variables
(e.g. disease or no disease; alive or dead).

 The frequency measures we use with

dichotomous variables are ratios,
proportions and rates.
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 Rates, Ratios and
Proportions
 Before you learn about specific measures,
it is important to understand the
relationship between the three types of
measures and how they differ from each
other.
 All three measures are based on the same
formula:
x
y
Ratio, proportion, rate = ×10n
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 Rates, Ratios and
Proportions

10n (10 to the nth power), is a constant that we

use to transform the result of the division
into a uniform quantity. The size of 10n
may equal 1, 10, 100,1000 and so on
depending upon the value of n.

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Rates, Ratios and
Proportions
 For example,
 100 = 1
 101 = 10
 102 = 10 × 10 = 100
 103 = 10 × 10 × 10 = 1000
 You will learn what value of 10n to
use when you learn about specific
ratios, proportions, and rates.

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 Rates, Ratios and
Proportions

★ Ratio
• The quotient of 2 numbers
• Numerator NOT necessarily INCLUDED in the
denominator
• Allows to compare quantities of different nature

= 5 / 2 = 2.5 / 1
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 For example, the sex of children attending
an immunization clinic could be compared
in either of the following ways:

 In the first option, x (female) is completely

independent of y (male).
 In the second, x (female) is included in y (all).
Both examples are ratios.
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★ Proportion
• The quotient of 2 numbers
• Numerator NECESSARELY INCLUDED
in the denominator
• Quantities have to be of same nature
• Proportion always ranges between 0 and 1
• Percentage = proportion × 100

2
--- = 0.5 ×100 = 50%
4

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 Of the two ratios shown above,
 the first is not a proportion, because
x is not a part of y.
 The second is a proportion, because
x is part of y.

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★ Rate
• The quotient of 2 numbers
• Speed of occurrence of an event over time
Numerator
- number EVENTS observed for a given time

Denominator
- population in which the events occur
(population at risk)
- includes time

Observed in 1998
2
----- = 0.02 / year
100
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 rate, is often a proportion, with an added
dimension: it measures the occurrence of
an event in a population over time.
 The basic formula for a rate is as follows:

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 Notice three important aspects of this
formula.
 The persons in the denominator must reflect the
population from which the cases in the numerator
arose.
 The counts in the numerator and denominator
should cover the same time period.
 In theory, the persons in the denominator must
be “at risk” for the event, that is, it should have
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been possible for them to experience the event.19
Rates and Proportions
• Rates: tell us how fast the disease is
occurring in a population
• Proportions: tell us what fraction of the
population is affected
• Rates and Proportions can be used to estimate
the extent and significance of disease burden in
a community or population

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 As you can see from the above discussion,
ratios, proportions, and rates are NOT three
distinctly different kinds of frequency
measures. They are all ratios:
 proportions are a particular type ratio, and
some rates are a particular type of
proportion.

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 In epidemiology, however, we often
shorten the terms for these
measures in a way that makes it
sound as though they are completely
different. When we call a measure a
ratio, we usually mean a
nonproportional ratio;
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 when we call a measure a
proportion, we usually mean a
proportional ratio that doesn’t
measure an event over time, and
when we use the term rate, we
frequently refer to a proportional ratio
that does measure an event in a
population
03/20/09 over time. 23
 We also use ratios, proportions, and,
most important rates to describe
three aspects of the human
condition:
 morbidity (disease),
 mortality (death),
 and natality (birth).
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Morbidity Frequency
Measures

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 In public health
terms, disease
includes illness,
injury, or disability.

 To describe the presence of

disease in a population, or the
probability (risk) of its occurrence,
we use one of the morbidity
frequency measures.

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 Table 1 shows several morbidity
measures.

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 All of these can be further elaborated into
specific measures for age, race, sex,
or some other characteristic of a
particular population being described.

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Table 2. shows a summary of the formulas for
frequently used morbidity measures.

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 I will describe how you calculate
each of the morbidity measures
and when you would use it later.

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 Incidence Rate
 Definition:
Incidence refers to the occurrence of
new cases in a population during a
given period of time.

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 Incidence Rate
 Incidence rate is the most common
way of measuring and comparing the
frequency of disease in populations.
 We use incidence rates instead of raw
numbers for comparing disease
occurrence in different populations
because rates adjust for differences in
population sizes.
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 Incidence Rate
 Rate of development of disease during a
given period of time.
 The incidence rate expresses the
probability or risk of illness in a population
over a period of time.
 It is used to estimate the risk of developing
a disease in a specified population during a
specified period of time.

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Incidence Rate
 Since incidence is a measure of risk,
when one population has a higher
incidence of disease than another, we
say that the first population is at a
higher risk of developing disease than
the second, all other factors being
equal.
 We can also express this by saying that
the first population is a high-risk group
relative to the second population.
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 Incidence Rate
 An incidence rate (sometimes
referred to simply as incidence) is a
measure of the frequency with which
an event, such as a new case of
illness, occurs in a population over a
period of time.

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 Incidence Rate
 The formula for calculating an
incidence rate as follows:

new cases ocurring during a given time period

Incidence rate = ×k
population at risk during the same time period

k =10n,
n=2,3,4,5,6

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 Incidence Rate
 Three key elements:
 Only new cases included in numerator

 Total population at risk in the

denominator
 Time element – period over which new

cases developed

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 Incidence rate
　　　　　 -
numerator
 The numerator of an incidence rate
should reflect new cases of disease
which occurred or were diagnosed
during the specified period.
 The numerator should not include
cases which occurred or were
diagnosed earlier.
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 Incidence rate
　　　　　 -
denominator
 Notice that the denominator is the
population at risk. This means that persons
who are included in the denominator should
be able to develop the disease that is being
described during the time period covered.
 Unfortunately, unless we conduct a special
study, we usually cannot identify and
eliminate persons who are not susceptible
to the disease from available population
data.
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 Incidence rate
　　　　　 -
denominator
 In practice, we usually use Census population
counts or estimates for the midpoint of the time
period under consideration.
 If the population being studied is small and very
specific, however—such as a nursing home
population—we can and should use exact
denominator data.

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Incidence rate
　　　　　 -
denominator
 The denominator should represent
the population from which the
cases in the numerator arose.
 E.g. : If the numerator was limited
to civilian cases, it was necessary
for us to restrict the denominator
to civilians as well.

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 Incidence rate
　　　　　 -
denominator
 Depending on the circumstances, the most
appropriate denominator will be one of the
following:
 average size of the population over the time

period.
 size of the population (either total or at risk)

at the middle of the time period.

 size of the population at the start of the

time period.
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 Incidence rate
　　　　　 -10n
 For 10n, any value of n can be used.
 For most nationally notifiable
diseases, a value of 100,000 or 105 is
used for 10n.
 Otherwise, we usually select a value
for 10n so that the smallest rate
calculated in a series yields a small
whole number (for example, 4.2/100,
not 0.42/1,000; 9.6/100,000, not
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 Incidence rate
　　　　　 -10n
 Since any value of n is possible, the
investigator should clearly indicate
which value is being used. If we
selected a value of 100,000, our
incidence rate is reported as “297.4
per 100,000.”

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 Incidence rate
　　　　　 -time 　
 Rates imply a change over time.
 For disease incidence rates, the
change is from a healthy state to
disease. The period of time must
be specified.
 For surveillance purposes, the period
of time most commonly used is the
calendar year, but any interval may
be used as long as the limits of the
interval
03/20/09 are identified. 45
Incidence rate
　　　　　 -types 　
 When the denominator is the size of the
population at the start of the time
period, the measure is sometimes called
cumulative incidence.
 This measure is a proportion, because
all persons in the numerator are also in
the denominator. It is a measure of the
probability or risk of disease, i.e.,
what proportion of the population will
develop illness during the specified time
period.
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Incidence rate
　　　　　 -types 　　
　　　　　　　
 In contrast, the incidence rate is
like velocity or speed measured in
miles per hour. It indicates how
quickly people become ill
measured in people per year.

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 Cumulative Incidence
 There are two types of Incidence rates :
1. Cumulative Incidence (CI): is the
proportion of people who become diseased
during a specified period of time.

Number of new cases of a disease during a specific period

×k
Total population at risk

k =10n,
n=2,3,4,5,6
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 Cumulative Incidence
 CI provides an estimate of the
probability, or risk that an individual will
develop a disease during a specified
period of time.
 The time period must be clearly
specified when reporting the CI.

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 Cumulative Incidence
 The CI assumes
 That the entire population is at risk at
the beginning of the study period
 That the populations has been followed
for the specified time interval

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 Cumulative Incidence
 In 2000:
 733,151 new cases of gonorrhea were
reported among the United States civilian
population.
 The mid-year civilian population was
estimated to be 246,552,000.

CI=[733,151/246,552,000] x 1,000=
2.97
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per 1000 population. 51
 Incidence Density
2. Incidence density (ID) = measure of risk
in a changing population where people are
free of disease at start and observed for
onset of disease for different time periods
 Shows how rapidly cases develop

 In presenting an incidence density, it is

essential to specify the relevant time units.

-i.e. number of cases per person-day,
person-month, person-year, etc.
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 Incidence Density
 Person-time is the number of persons
at risk for disease multiplied by the
length of time they are observed for
onset of disease
 Person years = # of person × # of
years followed up

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 Incidence Density
 Example: In a cohort study, 600 contraceptive
users were followed over the course of three years
as follows:
 100 women for 1year
 200 women for 2 years

300 women for 3 years
 The number of person-years of observation in this
study is:
 100 women x 1 = 100 person-years

 200 women x 2 = 400 person-years

 300 women x 3 = 900 person-years

 03/20/09
Total = 1400 person-years 54
Incidence Density
 Of these 600 people
 10 developed thromboembolism
 The incidence rate of
thromboembolism is calculated as:
 (10/1400)*k = 7.1 per 1000 person
years of follow up.

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 Prevalence Rate
 Prevalence, sometimes referred to as
prevalence rate, Is the proportion of
persons in a population who have a
particular disease or attribute at a specified
point in time or over a specified period of
time.

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 Prevalence Rate
The formula for presence of disease is:
all new and pre - existing cases during a given time period
Prevalence = ×k
population during the same time period

k =10n

The formula for prevalence of an

attribute is:and pre - existing attribute during a given time period
all new
Prevalence = ×k
population during the same time period

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 Prevalence Rate

 Gives an indication of the “burden” of

disease

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Prevalence Rate
 The value of 10n is usually 1 or 100
for common attributes.
 The value of 10n may be
1,000,100,000, or even 1,000,000
for rare traits and for most
diseases.

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 Prevalence Rate
There are two types of prevalence:
1. Point prevalence: is the presence
of a disease at a single point in time
(snap shot).

Number of existing cases at a specific point of time

×k
Total mid - point population at risk

k =10n,
n=2,3,4,5,6
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 Prevalence Rate
 The amount of disease present in a
population is constantly changing.
 Sometimes, we want to know how much of
a particular disease is present in a
population at a single point in time—to get
a kind of “stop action” or “snapshot” look
at the population with regard to that
disease.
 We use point prevalence for that
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 Prevalence Rate
 Point prevalence is not an incidence
rate, because the numerator
includes pre-existing cases;
 it is a proportion, because the
persons in the numerator are also in
the denominator.
03/20/09 62
 Prevalence Rate
 At other times we want to know how
much of a particular disease is present
in a population over a longer period.
Then, we use period prevalence.

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 Prevalence Rate
2. Period Prevalence: the presence of a
disease at a particular time interval .

Number of existing cases at a specific period of time

×k
Total mid - period population at risk

 Prevalence usually refers to point

revalence
k =10n,
n=2,3,4,5,6
03/20/09 64
 Prevalence Rate
 The numerator in period prevalence is
the number of persons who had a
particular disease or attribute at any
time during a particular interval.
 The interval can be a week, month, year,
decade, or any other specified time
period.

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 Relationship Between
Prevalence and Incidence
 The prevalence and incidence of disease are
frequently confused. They are similar, but
differ in what cases are included in the
numerator.
 Numerator of Incidence = new cases
occurring during a given time period
 Numerator of Prevalence = all cases
(existing and new)
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 As you can see, the numerator of an
incidence rate consists only of persons
whose illness began during a specified
interval.
 The numerator for prevalence includes

all persons ill from a specified cause

during a specified interval (or at a
specified point in time) regardless of
when the illness began. It includes
not only new cases, but also old cases
during the specified interval.
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 Relationship Between
Prevalence and Incidence

 Prevalence and Incidence are related

by average duration (D) of disease in
a stable population

03/20/09 68
 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.

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 We often use prevalence rather
than incidence to measure the
occurrence of chronic diseases
such as osteoarthritis which have
long duration and dates of onset
which are difficult to pinpoint.

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Relationship Between
Prevalence and Incidence
Incidence

Prevalence Deaths,
Duration Cured,
Lost...

P=ID
03/20/09 71
 Relationship Between
Prevalence and Incidence
 If a disease lasts a long time, there will be
higher prevalence in the population
 If incidence is low but those affected have
the condition for long = the prevalence will
be high relative to the incidence
 If disease is short-lived, there will be low
prevalence in the population
 If incidence is high but the disease duration
is short then the prevalence will be low
relative to the incidence
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 Relationship Between
Prevalence and Incidence
 Example: a follow up study of the
Framingham data showed males and
females had same IR for heart disease
but females had a higher prevalence
of disease

 – WHY?

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Relationship Between
Prevalence and Incidence
 PR = What proportion of the
population has this condition?

 IR = At what rate do new cases

arise over time in the population?

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 Relationship Between
Prevalence and Incidence
 Example: in Richmond City, 2006, there
were a total of 5,000 hepatitis B cases of
which 1,000 were newly diagnosed.
 The total population of Richmond City is
200,000.
 Prevalence in 2006:
(5,000/200,000)*1000=25 per 1,000
population
 Incidence
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in 2006: (1,000/200,000)* 75
Uses of Prevalence and
Incidence Measures

 Prevalence is mostly used for

planning, evaluating
 Incidence is used to identify causal
relationships

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 Factors which increase or decrease prevalence rate

Rates Are Increased by Rates Are Decreased by

Immigration of ill cases Immigration of healthy persons

Emigration of healthy persons Emigration of ill cases

Immigration of susceptible cases or Improved cure rate of cases

those with potential of becoming
cases
Increased death rates from the diseases

Prolongation of life of cases Decrease in occurrence of new cases

without cure (increase of duration
of disease) Shorter duration of disease

Increase in occurrence of new cases Death

(increase in incidence)
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 Attack Rate
Attack Rate: Is a variant of an
incidence rate, applied to a narrowly
defined population observed for a
limited time, such as during an
epidemic or outbreak of a disease.
 It is usually expressed as a percent, so
10n equals 100.

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 Attack Rate
 For a defined population (the population at risk),
during a limited time period,

No. of new cases among the population during the period

Attack rate = × 100
Population at risk at the beginning of the period

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 Attack Rate
 Example: Of 75 persons who attended a
church picnic, 46 subsequently developed
gastroenteritis.
 To calculate the attack rate of
gastroenteritis we first define the numerator
and denominator:
 x = Cases of gastroenteritis occurring
within the incubation period for
gastroenteritis among persons who
attended
03/20/09
the picnic = 46 80
 Attack Rate

The attack rate of gastroenteritis is:

46
×100 = 61%
75

The risk of developing gastroenteritis in this

population was 61%.

03/20/09 81
 Attack Rate
 Notice that the attack rate is a proportion
—the persons in the numerator are also in
the denominator.
 This proportion is a measure of the
probability or risk of becoming a case.
 In the example above, we could say that,
among persons who attended the picnic,
the probability of developing
gastroenteritis was 61%, or the risk of
developing
03/20/09
gastroenteritis was 61%. 82
 Secondary Attack Rate
 Secondary attack rate: is a measure of
the frequency of new cases of a disease
among the contacts of known cases.
 The formula is as follows:
No. of case among contacts of primary cases during the period
Secondary attack rate = ×k
Total number of contacts

k =10n,
n=2,3,4,5,6
03/20/09 83
 To calculate the total number of household
contacts, we usually subtract the number of
primary cases from the total number of
people residing in those households.

03/20/09 84
 Secondary Attack Rate
 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 were 32
 One incubation period later, 5 family
03/20/09 85
members of the 7 infected children also
03/20/09 86
 Calculate the attack rate in the
child care center and the
secondary attack rate among
family contacts of those cases.

03/20/09 87
 1. Attack rate in child care center:
 x = cases of hepatitis A among
children in child care center = 7
 y = number of children enrolled in
the child care center = 70
x 7
 Attack rate = ×100 = × 100 =
y 70
10%
03/20/09 88
 2. Secondary attack rate:
 x = cases of hepatitis A among family contacts of
children with hepatitis A = 5
 y = number of persons at risk in the families (total
number of family members—children already
infected) = 32 − 7 = 25
 Secondary attack rate
x
= ×100 =5 × 100 = 20%
y 25
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