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 Epidemiology describes the frequency and

distribution of diseases.
 In
epidemiology we also try to find those factors
which influence the occurrence of diseases.
(e.g.: environmental, social, genetical, behavioural, etc.)

Our ultimate aim is to understand the causes of


diseases
 Number of cases
 Incidence
 Prevalence To describe disease frequency in a
 Proportional mortality population
 Standardized ratios

 Relative risk To analyse the association between


 Odds ratio the disease and its risk factors

 Attributable risk
 Life years lost (To quantify the impact of a
 Disability adjusted life year (DALY) disease or a risk factor in a
 Quality adjusted life year (QALY) population)
 Proportionate mortality ratio
• Simplest/oldest measure in epidemiology

• Number of people with the disease (cases) or number


of people with the risk factor

• Useful for allocation of health resources

• Limited usefulness for epidemiologic purposes


without knowing the size of the source population
Numerator Cases
 Fraction: =
Denominator Population

 Ratio: Any number in relation to another. (without a


specified relationship between the numerator and denominator)

 Proportion: A ratio where the numerator is included in the


denominator (relation of a part to the total)

 Rate: A ratio where the outcome is measured over time

Frequency data must be always described in the context of the place,


time and the observed population!!!!!
Incidence Rate
New cases of a disease in the population in a period of time

Cumulative incidence rate = Number of new cases over a period of time Xk


Population at risk over that period of time

Practically: - k = 100 or 1000 → Rate = % or ‰


- population at risk= population usually at the beginning or
the middle of the time period

Number of new cases over a period time


Incidence density =
The amount of time that the study population has spent at risk

Practically:
Person-time denominator = Sum of individual time periods
• Diseased, lost, late joined, etc → Particular time they spent in the study
• Other individuals = duration of the observation
Cumulative incidence Incidence density

• Easy to interpret •No easy interpretation

•Can not handle losses of •Very flexible in coping with


follow up, deaths, lately people entering and leaving
entered people. study at different times.
•Incidence density gives the
•Can be used to calculate
best estimate of the true risk of
relative risk
acquiring disease.
•Can be used to calculate
relative risk

.
Prevalence Rate
All cases of a disease in the population in a time period or a time point

Number of all cases (old+new) over a period of time


Period prevalence = Population at risk over a period of time Xk

Number of all cases at a timepoint


Point prevalence = Population at risk at the timepoint Xk

Lifetime = Number of cases who ever had the disease during lifetime
Xk
prevalence Population at risk (at the begining of the period)
The bath of incidence and prevalence

Incident cases

Prevalent cases

Deaths, emigrations and recovery

Bhopal
The bath in the context of the population
Births
Recoveries

Population reservoir Immigration

Incident cases

Prevalent cases Emigrant cases, unmeasured


cases occurring abroad, and
deaths

Emigrant and non-measured cases,


Recoveries deaths

Bhopal
In fixed population:
Point Prevalence = Incidence rate x Average duration of the disease

 Cancer of the pancreas • Common cold


• Incidence low – Incidence high
• Duration relatively short – Duration short
• Prevalence low – Prevalence low

 Adult onset diabetes • Essential hypertension


• Incidence low – Incidence high
• Duration long – Duration long
• Prevalence high – Prevalence high
1. Incidence always requires a duration, prevalence may or may not.

2. In incidence, the unit of analysis is the event, in prevalence, it is the person.


Thus incidence may exceed 100% (e.g. annual incidence of colds).
Prevalence can never exceed 100%.

3. Incidence generally requires an initial disease-free interval before counting


starts, because incidence is measured only in those at-risk of disease. Those
who already have the disease are excluded from the denominator).

4. Incidence is generally used for acutely acquired diseases,


Prevalence is used for more permanent diseases, conditions or attributes of
ill-health (risk factors).

5. Incidence is more important when thinking of etiology of the disorder,


Prevalence when thinking of societal burden of the disorder including the
costs and resources consumed as a result of the disorder.
Exercise 1.
Figure 1 is a study about the frequency of high blood pressure among randomly
selected adults. 20 people were observed over the year. The investigators could
monitor 5 people in a time and each monitoring period took three months long.
Horizontal lines show the presence of high blood pressure, and the shading shows
the periods of the fieldwork.
 Q1: What is the point prevalence rate in January, July,
December?
 Q2: What is the period prevalence rate?
 Q3: What is the cumulative annual incidence rate?
 Q4: What is the lifetime prevalence rate?
 Q5: Have the investigators identified all cases?
 Q6: What would be the effect of doing the study in a
different order, say started with the group 16-20,
followed by the group 11-15, etc?
 A1: The point prevalence in Jan:10%, July:20%,
Dec:25%
 A2: 25% (5/20)
 A3: 12.5% (3/18)
 A4: We do not know
 A5: 1 case is missed (No.12)
 A6: 2 cases would have been missed (No.12 and 18)
Figure 2.2 is a study about the frequency of knee injuries among randomly selected
football players. 20 people were observed over the year. The investigators could
monitor 5 people in a time and each monitoring period took three months long.
Horizontal lines show the presence of high blood pressure, and the shading shows
the periods of the fieldwork.
 Q1: What is the point prevalence rate in January, July,
December?
 Q2: What is the period prevalence rate?
 Q3: What is the cummulative annual incidence rate?
 Q4: Have the investigators identified all cases?
 Q5: What would be the effect of doing the study in a
different order, say started with the group 16-20,
followed by the group 11-15, etc?
 A1: Point prevalence in Jan:15%, July:20% Dec:10%
 A2: 30% (6/20)
 A3: 17.6% (3/17)
 A4: No missed case
 A5: 3 cases would have been missed (No.:2, 5, 17)
 Imagine a population of 10000 new army recruits. Your
interest is in the incidence and prevalence of gunshot
wounds on war duty. Assume all gunshot wounds lead to
permanent visible damage. You follow the recruits for one
year. All of the study population survive, all medical
records are available, and all are available for interview
and examination. Assume that the occurrence of gunshot
wounds is spread evenly through the year, and that at
recruitment none had such a wound. Over the year you
find that 20 recruits had a gunshot wound.
 Q1: What is the cumulative incidence rate of gunshot
wounds using the population at risk at the beginning
of the study?
 Q2: What is the incidence rate based on the person-time
denominator?
 Q3: What is the point prevalence rate of having had a
gunshot wound at the beginning, middle and end of
the year?
 Q4: What is the period prevalence rate over the year?
 A1: The incidence rate (cumulative) of first scarring wounds, based on
the denominator at the beginning of the study, is 20/10,000/year =
2/1,000 or 0.2%
 A2: The total person-years of observation is 9990 (9980 given by those
unwounded, and 10 by those 20 people who were wounded for they
give, on average, 0.5 years). The result is 20/9990 person years i.e.
0.002002 per person-years, or 2.002 per 1,000 person-years. For such a
low rate the incidence estimated by the person time denominator is
virtually identical-but you could repeat the exercise with an example
where 200 people had a gunshot wound.
 A3: The point prevalence rate (proportion) at the beginning is zero, and
at six months, on average half of all cases will have occurred, so it is
10/10,000 and by the end of the year it is 20/10,000.
 A4: The period prevalence at one year is also 20/10,000.
Frequency data can be calculated for diseases and for
deaths as well:

 Morbidity rate – disease rate


 Mortality rate – death rate

 Lethality (Case fatality rate)

Number of people who died because of the disease


L (%) = X 100
Number of people who acquired the disease

• Represents the severity of the disease


• Used mainly in infectious disease epidemiology
 Number of cases
 Incidence
 Prevalence To describe disease frequency in a
 Proportional mortality population
 Standardized ratios

 Relative risk To analyse the association between


 Odds ratio the disease and its risk factors

 Attributable risk
 Life years lost (To quantify the impact of a
 Disability adjusted life year (DALY) disease or a risk factor in a
 Quality adjusted life year (QALY) population)
 Proportionate mortality ratio
 Number of cases
 Incidence
 Prevalence To describe disease frequency in a
 Proportional mortality population
 Standardized ratios

 Relative risk To analyse the association between


 Odds ratio the disease and its risk factors

 Attributable risk
 Life years lost (To quantify the impact of a
 Disability adjusted life year (DALY) disease or a risk factor in a
 Quality adjusted life year (QALY) population)
 Proportionate mortality ratio
 Attributable risk (AR)

 Population attributable risk (PAR)

These measures assume that the association between exposure


and disease has already been shown to be causal.
Incidence

AR

PAR

Non exposed Population Exposed


as a whole
Attributable risk (AR)
• The excess incidence (risk) of the disease in the exposed population which
can be attributed to the risk factor.
AR = Iexposed – Inon-exposed

Attributable risk fraction (ARF)


• The excess proportion of the incidence in the exposed population which can be
attributed to the risk factor

I exposed – I non-exposed =
RR-1
ARF=
I exposed RR
May be expressed as percentage (ARF%)

• It shows that what proportion the incidence would decrease in the exposed
group if the risk factor was not present
Population attributable risk (PAR)
 The excess incidence of the disease in the total population which
can be attributed to the exposure.
PAR = Ipopulation - Inon-exposed

Population attributable risk fraction (PARF)


 The excess proportion of the incidence in the total population
which can be attributed to the exposure
Ipopulation – Inon-exposed
PARF = = P (RR - 1)
Ipopulation P (RR - 1) + 1

May be expressed as percentage (PARF%) (P = proportion of the exposed persons in


the population)

 It shows that what proportion the incidence would decrease in the


population if the risk factor was not present
 PYLL = reference age – age at which deaths occur

(reference age = average life expectancy at birth)


2000 1892
1800

1600
1458
1400

1200
971
1000 919

800
589
600

400 278
200 116
57
0
Quelle: http://www.oecd-ilibrary.org
Quelle: http://www.oecd-ilibrary.org
QUALY= Quality Adjusted Life Years

DALY= Disability Adjusted Life Years

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