Basic measurements in

epidemiology
 Measurements used in epidemiology
• Measurement of mortality
• Measurement of morbidity
• Measurement of disability
• Measurement of natality
• Measurement of disease attributes
• Measurement of health care services
• Measurement of the risk factors
• Measurement of demographic variables

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TOOLS OF MEASUREMENT

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 Tools of measurement
• Proportion
• Rate
• Ratio

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 Proportion
• Usually expressed as a percentage %
– Numerator (which is part of denominator)
– Denominator
– Multiplier
– No time factor

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Proportion – ‘real’ example
• What proportion of the population is
suffering from diabetes?

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 Rate
Contains
• Numerator (which is part of denominator)
• Denominator
• Multiplier
• Time period

• Usually expressed per 100 / per 1000 population

• It has a time dimension, whereas a PROPORTION
does not
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Rate – example

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 Rate – example
𝑁𝑜.𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑖𝑛 𝑜𝑛𝑒 𝑦𝑒𝑎𝑟
• Death rate = X 1000
𝑇𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑖𝑛 𝑡ℎ𝑎𝑡 𝑦𝑒𝑎𝑟

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 Ratio
Contains
• Numerator (not part of denominator)
• Denominator

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Ratio – example

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Ratio – example

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Ratio – example

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MEASUREMENT OF MORBIDITY

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Incidence
Occurrence of new cases
•

Prevalence
Existence of all new & old cases.
 Prevalence:-how many people in
a population currently have the
disease (Photograph)

 Incidence:-
how many people are
diagnosed each year (Film)
Cure rate
Incidence
Occurrence of new cases
•

Prevalence
Existence of all new & old cases.
 Prevalence:-how many people in
a population currently have the
disease (Photograph)

 Incidence:-
how many people are
diagnosed each year (Film)
Cure rate
New cases
 • The rate at which acute
disease is spreading --
Attack rate used during epidemics
& expressed in %.

Secondary • % of exposed persons

attack rate developing disease after
primary case exposure
 • Prevalence at any
Point given point of time.
prevalence • 4% TB cases on 1st April

•Prevalence at a given
Period period of time.
prevalence •Period will be 1year.
 Prolongation
of life
Incidence without
increases. cure.

Longer
duration of
disease

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 Shorter duration of diseases.
 Improved cure rate.
 Incidence decreases.
 Emigration of new cases.
 Under reporting of cases.
Improved cure rate.

Short duration of
disease.

Incidence decreases
 Measurement of morbidity
• Incidence
– Occurrence of new cases
• Prevalence
– Existence of new and old cases

• Incidence – how many people with the disease

are newly diagnosed each year (like video)
• Prevalence - how many people in a population
currently have the disease (like snapshot)

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 Incidence
No. of 𝐍𝐄𝐖 cases of a disease
in a particular time period
= Total population at risk during X 1000
the same time period

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 Incidence – example

JANUARY 1, 2016 DECEMBER 31, 2016

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 Special incidence rates
• Attack rate
• Secondary attack rate

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 Uses of incidence rate
• For taking action to control disease
• More suited for acute or infectious conditions
• For research

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 Example of use of incidence

This news article is giving only the numerators,

Without denominator, it is hard to place much importance
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Example of use of incidence

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 Points to remember about incidence

• Refers only to new cases

• Not influenced by duration of disease
• Refers to a particular time period
• Denominator is people at risk

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 Prevalence
No.of 𝐎𝐋𝐃 𝐚𝐧𝐝 𝐍𝐄𝐖 cases of a disease
in a particular time point/period
= Total population at risk during X 1000
the same time period

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 Types of prevalence
• Point prevalence
• Period prevalence

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 Point prevalence – example

JANUARY 1, 2016 DECEMBER 31, 2016

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Period prevalence – example

JANUARY 1, 2016 DECEMBER 31, 2016

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 Prevalence increases
• Longer duration of disease
• Prolongation of life with treatment
• Increase in incidence
• Immigration of new cases
• Better reporting of cases
• Emigration of healthy people

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 Prevalence decreases
• Shorter duration of diseases
• Improved cure rate
• Decrease in incidence
• Emigration of new cases
• Under reporting of cases
• Immigration of healthy people

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 Uses of prevalence
• Magnitude of disease problems
• Identify potential high-risk populations
• Administrative and planning purposes, e.g.,
hospital beds, manpower needs, rehabilitation
facilities

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Example of use of prevalence

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Example of use of prevalence

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Points to remember about prevalence

• Refers to new and old cases

• Influenced by duration of disease
• Refers to a particular time period
• Denominator is people at risk

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Relation between incidence &
prevalence

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 Relation between incidence &
prevalence
• Prevalence = Incidence X duration

• Incidence = 10 cases/1000 population/year

• Mean duration of disease = 5 years
• Prevalence = 10 x 5 = 50 per 1000 population

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MEASUREMENT OF MORTALITY

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 Crude Death Rate.
 Specific death rate.
 Case fatality rate.
 Proportional mortality rate.
 Survival rate.
 Standardized death rate.
 Number of deaths from all causes, per 1000
estimated mid year population in one year in
a given place.

No deaths during one year

CDR = X 1000
Mid year population
Total population in Madurai in 2018

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No. of deaths in Madurai in 2018

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CDR in Madurai in 2018

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 Cause Specific death rate like
disease death rate, Road accident…

 Age specific-IMR, Child Mortality rate

 Sex specific death rate – MMR/female

 Period specific death rate–Death in May

Total population in Madurai in 2018

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No. of deaths in Madurai in 2018

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Cause of death – cholera

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Cholera specific death rate in Madurai
in 2018

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 Proportion or % of deaths due to particular
cause out of total deaths.

 It measures the disease burden.

Under 5, No of deaths below 5 years

proportional = -------------------- X 100
mortality rate Total No all of deaths
Total population in Madurai in 2015

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No. of deaths in Madurai in 2015

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Total deaths

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Cause of death – cholera

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Proportional mortality rate of cholera

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 CDR
Total population (MYP)

Total deaths – all causes Specific DR

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Cholera deaths PMR
 Percentage of particular cases dying
during particular disease epidemic.

 Killing power of disease particularly

acute diseases

No of deaths due to cholera

 CFR= ----------------------- X 100
Total No of cholera cases
Total no. of cholera cases

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No. of people died due to cholera

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Total no. of cholera cases

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 Percentage of the treated patients remaining
alive at the end of 5 years treatment.

 Yard stick for assessing the standard of

therapy in cancer.

 pts alive at the end of 5 yrs

Sur = ---------------------- X 100
vival Total No of pts treated
Rate
 What is standardization?

You: My salary has Ur friend: My salary

doubled this month has also doubled

 
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 What is standardization?

Rs. 1 Lakh ¥. 1 Lakh = Rs. 10 Lakh

Rs. 2 Lakh ¥. 2 Lakh = Rs. 20 Lakh
Gain = Rs. 1 Lakh Gain = Rs. 10 Lakh
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 What is standardization?

Rs. 1 Lakh = $ 1,500 ¥. 1 Lakh = $ 15,000

Rs. 2 Lakh = $ 3,000 ¥. 2 Lakh = $ 30,000
Gain = $ 1,500 Gain = $ 15,000
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 What is standardization?

You: My salary has Ur friend: My salary

doubled this month has also doubled

 
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Direct standardization

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 Crude rates
Madurai Population Deaths Death rate
per 1000
0-64 53,500 446 8.3

Chennai Population Deaths Death rate

per 1000
0-64 92,000 850 9.2

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 Age specific rates
Madurai Population Deaths Death rate
per 1000
0-24 21,500 123 5.7
25-64 32,000 323 10.0

Chennai Population Deaths Death rate

per 1000
0-24 32,000 150 4.6
25-64 60,000 700 11.6

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 Standard population

Standard Population
0-24 156,000
25-64 45,000

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 Standardization for Madurai
Standard Population Madurai Expected
rates deaths
0-24 156,000 5.7 889
25-64 45,000 10.0 450
Total 201,000 1,339

Age Population Total deaths Standardized

crude rate
0-64 201,000 1,339 6.6
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 Standardization for Chennai
Standard Population Chennai Expected
rates deaths
0-24 156,000 4.6 718
25-64 45,000 11.6 522
Total 201,000 1,240

Age Population Total deaths Standardized

crude rate
0-64 201,000 1,240 6.1
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 Standardized rates
Madurai Population Deaths CDR per Std. DR
1000 per 1000
0-64 53,500 446 8.3 6.6

Chennai Population Deaths CDR per Std. DR

1000 per 1000
0-64 92,000 850 9.2 6.1

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Indirect standardization

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Standardized mortality ratio
Age National death rate
per 1000
25-34 3
35-44 5
45-54 8
55-64 25

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 Standardized mortality ratio
Age Doctor Observed
population deaths
25-34 300 *
35-44 400 *
45-54 200 *
55-64 100 *
Total 1000 9.0

Crude death rate for doctors is 9.0 per 1000

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 Standardized mortality ratio
Age National Doctor Observed Expected
rate population deaths deaths
25-34 3 300 * 0.9
35-44 5 400 * 2.0
45-54 8 200 * 1.6
55-64 25 100 * 2.5
Total 1000 9.0 7.0

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 Standardized mortality ratio
Observed deaths
SMR = X 100
Expected deaths

SMR = 9/7 X 100 = 129

It means doctors experience 29% more

mortality than the general population
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 Summary
• There are various measures of mortality
• Each one has its own purpose and
disadvantages
• Standardization is a method for making rates
comparable between regions

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 Summary
• Incidence and prevalence are finer
measurements of health as compared to
death rates
• They help us to measure the effectiveness of
disease control measures

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 Take home messages
• Proportion, rate and ratio – basic tools
• CDR is a simple measure of death/health
• Standardization is needed for comparability
• Incidence reflects new cases only
• Prevalence reflects new and old cases
• Incidence and prevalence are related
• Mortality measures are important, morbidity
measures give a better idea of health

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 Review 1
• It was reported that the incidence of dengue
was increasing every year in Madurai. This
could mean all EXCEPT,

a) Control of mosquitoes has failed

b) Reporting of dengue cases has improved
c) Treatment for dengue has failed
d) Public awareness on dengue has increased
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 Review 2
• Prevalence of Diabetes is increasing every year in
India. This could mean all EXCEPT,

a) Incidence of DM is increasing
b) Reporting of diabetes has increased
c) Diabetic patients are surviving longer due to
better treatment
d) Public awareness on diabetes has increased
e) None of the above

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 Review 3
• Examples of a disease with high incidence but
low prevalence include (multiple options)

a) Acute respiratory infection

b) Acute diarrhoea
c) TB
d) Leprosy

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 Review 4
• Examples of a disease with low incidence but
high prevalence include (multiple options)

a) Acute respiratory infection

b) Acute diarrhoea
c) TB
d) Leprosy

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 Review 5
• A new diabetes control programme was
introduced in Madurai. After 1 year, the
incidence and prevalence of Diabetes
increased. This means

a) The programme did not work

b) The programme worked
c) Data not sufficient
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 Review 6
• Disadvantages of crude death rate include
(multiple options)

a) Simple measure
b) Influenced by the age composition
c) Not comparable between countries
d) All of the above

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 Review 7
• Proportional mortality is useful for all EXCEPT

a) Understanding relative importance of diseases

as a cause of death
b) Determining measures for reducing preventable
mortality
c) Indicating the risk for population from dying due
to a particular cause
d) All of the above

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 Review 8
• Standardized rates can be calculated for

a) Age
b) Sex
c) Race
d) Literacy rate
e) All the above

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 Review 9
• Standardized mortality ratio requires all
EXCEPT

a) Age specific denom. for interest pop.

b) Age specific death rates for standard pop.
c) Age specific death rates for interest pop.
d) Crude death rate in interest pop.

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 Review 10
• A patient with Atherosclerotic heart disease for 7
years developed Acute myocardial infarction last
week and died today as a result of myocardial
rupture. What is the immediate cause of death?

a) Acute myocardial infarction

b) Atherosclerotic heart disease
c) Cardiac arrest
d) Rupture of myocardium

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 Review 11
• Mid year population is not the denominator
for (multiple options)

a) Age specific death rate

b) Cause specific death rate
c) Crude death rate
d) Proportional mortality rate
e) Case fatality rate

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