Measures of Morbidity

Measures of
morbidity and
mortality
Dr Anu Oommen
Associate Professor,
Community Health, CMC Vellore
“epidemiology”
• Disease frequency-magnitude (burden)
• Distribution of disease - time, place and person
• Determinants of disease-agent, risk factors, transmission
Why have epidemiologists?
Learning objectives
To learn how to measure burden of disease
Specific objectives
1. Describe and calculate measures of disease morbidity
2. Describe and calculate measures of mortality
Measuring burden of disease
Indicators of health status:
• Measures of morbidity
• Measures of mortality
• Measures of disability
• Other characteristics related to disease e.g.
demographic/environmental/social
Sources of data
• Routine
Vital events registration
Surveillance systems
Hospital records
Others: police records, nursing homes, insurers
• Research
Introduction to measurements
• Variable: characteristic of interest
• Types of variables:
Categorical
Numerical (discrete or continuous)
• Levels of measurement:*
Nominal e.g. male/female
Ordinal e.g. grades of cancer
Interval e.g. temperature
Ratio e.g. biochemical values
*Stevens SS. On the Theory of Scales of Measurement. Science 7 June 1946: Vol. 103 no.
2684 pp. 677-680DOI:10.1126/science.103.2684.677
The digital archives of Science, 1880-1996
Measures of central tendency
• Mean: mathematical average
• Mode: most commonly occurring value
• Median: middle value of the data
4,3,2,6,7,3,5,12
2, 3,3,4,5,6,7,12
Most appropriate measures
Nominal variables Mode, frequency %
Ordinal variables Median
Interval/ratio scale Mean

Tools of measurement
• Ratio : numerator is not part of the denominator
e.g. sex ratio females per 1000 males,
Child-woman ratio,
• Proportion: numerator is part of the denominator

e.g. % with diabetes in a population
• Rate: time dependent frequency of occurrence

e.g. mortality rates
Measures of morbidity
• Prevalence
• Incidence
Prevalence
• Prevalence is measured through cross sectional
studies
Tells us the magnitude of burden due to the disease
N
Point prevalence
C
P  X 100
N
C = # of observed cases at time t

N = Population size at time t
Measures the frequency of disease at a given

point in time
Expressed as % or per 1000, per 100,000

Period prevalence
CI
PP  X 100
N
• C = the # of prevalent cases at the beginning of the time
period.
• I = the # of incident (new) cases that develop during the

period.
• N = size of the population for this same time period.
• Exercise in handout (figure)

Quiz
A study to measure the prevalence of disabilities following
injuries was undertaken in a rural block. Five field workers were
employed and asked the following question during the single
home visit made to the participant’s house:
Do you have any visual/hearing/locomotor disability?
The study population of 1000 adults were interviewed between

1st July to 31st August, 2014
The prevalence of disability obtained was 10%.
Is this a point prevalence or a period prevalence?

Incidence
• Incidence measures occurrence of events –new
cases (e.g. deaths, development of disease,
accidents)
• Helps to understand public health importance of the

problem, trends
• Prevalence measures a state of having the disease
• Incidence is measured through cohort studies

Measuring incidence
Leon Gordis, 4th edn

Measuring incidence risk
Disease
40
Cohort of individuals free of

disease at baseline
e.g. N=100 No disease
60
Incidence risk or Cumulative Incidence

= new cases
Number of individuals at risk who were followed up for a
specified period of time
Risk or probability of getting the disease

Measuring incidence rate
40 diseased,
observed for 0.5 year
each = 20 pyears
Cohort of individuals free of
disease at baseline
e.g. N=100 60 disease free,
Observed for 60 X 1 =
60 pyears
Incidence rate (IR) or density ID): measures the speed with which new
cases develop
= new cases
sum of length of time at risk for each individual (person time)
= 40/80 pyears = 0.5 cases/pyear OR 50 cases per 100 pyears
Also very useful when there is a large % who are lost to follow up
(handout)
Incidence
Incidence risk OR Incidence rate Or
Cumulative incidence Incidence density
• Unit is events/ person time

• Denominator: population
at risk
• Incomplete follow up also

• Complete follow up for contributes to denominator
defined time period • Useful for chronic diseases ,
contraceptive studies
• Useful for acute conditions
e.g. 5 year survival rates, case e.g. no. of pregnancies/100 woman

years of contraceptive use
fatality rates,
Attack rates: incidence in
outbreaks
= no. attacked by disease/population at risk (exposed) X 100
Incidence risk or rate ??

Exercises
• Exercises 2, 3, 4
Quiz:
Is this an incidence risk, incidence rate or
prevalence?
• Case fatality rate for swine flu in 2014:
Proportion of deaths among those diagnosed to have swine flu in
2014
• % with diabetes in a town
• Number of cases with intussception following rotavirus vaccine per

1000 person years
• Contraceptive failure rate (Pearl Index): number of pregnancies per

100 woman years of use
• Congenital malformation rate among term newborns

Relationship between incidence
and prevalence
• Prevalence= Incidence X duration of disease
E.g. cancer prevalence in two countries
• Rich country A: high prevalence, low incidence
• Poor country B: low prevalence, high incidence
Why?
Effect of screening programs
on incidence
No of cases
Time
Effect of new treatment for a
chronic disease
• What would have happened when Insulin was introduced for
diabetes? Or ART for AIDS
A. Incidence would have decreased.

B. Incidence would have increased
C. Prevalence would have decreased
D. Prevalence would have increased
E. No change in prevalence or incidence
Effect of multidrug therapy on leprosy?

Summary
Measuring disease frequency: incidence and prevalence
Prevalence:
measured through cross sectional studies, tells us magnitude of
existing disease burden and need for interventions for
treatment
Incidence:
Measured through cohort studies, tells us trend of disease, need
for preventive measures (primary prevention)
Measured either as a risk or a rate (person time)
MEASURES OF MORTALITY
Mortality indicators
1. Crude death rate
= No of deaths per year/mid year population X 1000
Determines population size, distribution and structure
Bangladesh: 6/1000
India: 8/1000
Japan, Finland: 10/1000
Germany: 11/1000
5% elderly in Bangladesh c.f. 25% in Japan

2. Specific death rates:
a. Age or sex (or both) specific death rates
b. Cause or disease specific death rate

TB specific death rate
any other group specific (e.g. SES specific, region specific, etc.)
3. Case fatality rate
= no of deaths/no. of cases of disease X 100
4. Proportional mortality rate
a. Proportionate mortality rate/ratio for a disease
b. Under-5 proportionate mortality rate
c. Proportionate mortality for age 50 years and above
Proportionate mortality
Cardiovascular disease in the Netherlands, 1975 to 1995: decline in mortality, but increasing numbers of patients with chronic conditions
Reitsma et al . Heart 1999;82:52-56
Causes of death (Global)
2004
Global burden of disease, WHO
Global burden of disease, WHO 2004
exercises
1. In a town with a midyear population of 50,000 there were 200 cases of
tuberculosis on January 1st 2003. There were 50 new cases of tuberculosis during
the year, 10 died due to tuberculosis; 15 were cured and 5 of them migrated to
other community. The crude death rate for this community during 2003 was
10/1000. Calculate the following:
a. Period prevalence of tuberculosis for the year 2003

b. Incidence of tuberculosis in 2003
c. Case fatality rate
d. Proportional mortality rate for tuberculosis
2. In a town with a population of 100,000, there were 850 deaths in 2008. During
the year there was an epidemic of viral hepatitis A and 1200 individuals came down
with the illness. The proportionate mortality rate for hepatitis during 2008 was 2 %
a. Calculate crude death rate

b. Calculate the case fatality rate
c. What was the hepatitis specific mortality rate for 2008?
5. Life expectancy
LE at birth: The average number of years that a new born could
expect to live, if he or she were subject to the age-specific
mortality rates of a given period.
LE at a specific age e.g. age 60: the number of additional years a

person aged 60 would expect to live, on average, given current
age-specific mortality for ages 60 and over
6. Survival rates
% who have survived a disease from a specified
point in time
Comparing mortality experiences
http://cancerguide.org/scurve_basic.html
7. Age standardized rates
Used to compare mortality rates (or morbidity rates) of two
different populations
e.g. death rates among women in England enrolled in a cohort

study in 1972:
N= 1314 20 year death rate CRUDE DEATH RATE
Smokers 24/100
(582)
Non smoker 31/100

(732)
Age distribution of the women
Age group Smokers Non Smokers All
(% of total) (% of total)
18-24 55 (10) 62 (8) 117
25-34 124 (21) 157 (21) 281
35-44 109 (19) 121 (17) 230
45-54 130 (22) 78 (11) 208
55-64 115 (20 121 (17) 236
65-74 36 (6) 129 (18) 8% 65 and above 165
13 (2) 64 (9) among smokers cf.
75+ 27% among non 77
Total 582 732 smokers 1314
Here age is confounding the difference in death rates of smokers vs

non smokers
Age specific death rates
Age group % of deaths in % of deaths in All
each age grp each age grp
(smokers) (non smokers)
18-24 4% 2% 117
25-34 2% 3% 281
35-44 13% 6% 230
45-54 21% 15% 208
55-64 44% 33% 236
65-74 81% 78% 165
75+ 100% 100% 77
Total 582 732 1314
To avoid confounding due to
age:
Age standardized rate:
A hypothetical rate that would have been seen if the age
structure were that of a standard population.
• Calculate standardized death rates for both the populations

whose death rates you want to compare (here smokers and
non smokers).
• Use these age standardized rates to compare the mortality

experience of these two populations
• ..\MBBS\CEclass\standardization.xls
8. Special mortality rates
Maternal mortality rate

Infant mortality rate
Perinatal mortality rate
Summary
Measures of morbidity:
Incidence : occurrence of new cases in a disease free group

Very useful for acute diseases,
Studied using follow up studies (cohort studies)
Prevalence: % of population with disease at a point in time or

time period
More relevant for chronic diseases
THANK YOU

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Measures of

To learn how to measure burden of disease

• Mode: most commonly occurring value

• Median: middle value of the data

Ordinal variables Median

Interval/ratio scale Mean

• Proportion: numerator is part of the denominator

• Rate: time dependent frequency of occurrence

Tells us the magnitude of burden due to the disease

C = # of observed cases at time t

Measures the frequency of disease at a given

Expressed as % or per 1000, per 100,000

• I = the # of incident (new) cases that develop during the

• N = size of the population for this same time period.

• Exercise in handout (figure)

The study population of 1000 adults were interviewed between

The prevalence of disability obtained was 10%.

Is this a point prevalence or a period prevalence?

• Helps to understand public health importance of the

• Prevalence measures a state of having the disease

• Incidence is measured through cohort studies

Leon Gordis, 4th edn

Cohort of individuals free of

Incidence risk or Cumulative Incidence

Risk or probability of getting the disease

• Unit is events/ person time

• Incomplete follow up also

e.g. 5 year survival rates, case e.g. no. of pregnancies/100 woman

= no. attacked by disease/population at risk (exposed) X 100

Incidence risk or rate ??

• % with diabetes in a town

• Number of cases with intussception following rotavirus vaccine per

• Contraceptive failure rate (Pearl Index): number of pregnancies per

• Congenital malformation rate among term newborns

E.g. cancer prevalence in two countries

• Rich country A: high prevalence, low incidence

• Poor country B: low prevalence, high incidence

A. Incidence would have decreased.

Effect of multidrug therapy on leprosy?

Determines population size, distribution and structure

5% elderly in Bangladesh c.f. 25% in Japan

b. Cause or disease specific death rate

a. Period prevalence of tuberculosis for the year 2003

a. Calculate crude death rate

LE at a specific age e.g. age 60: the number of additional years a

e.g. death rates among women in England enrolled in a cohort

N= 1314 20 year death rate CRUDE DEATH RATE

Non smoker 31/100

Here age is confounding the difference in death rates of smokers vs

• Calculate standardized death rates for both the populations

• Use these age standardized rates to compare the mortality

Maternal mortality rate

Incidence : occurrence of new cases in a disease free group

Prevalence: % of population with disease at a point in time or

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