Disease Rates
Counting cases
One’s knowledge of science begins when he
can measure what he is speaking about and
express it in numbers Lord Kelvin (1824-1907)
To examine the transmission of disease in
human populations, we need to be able to
measure the frequency of disease occurrence
and of deaths from the disease.
Measures
How do we express the extent of morbidity
and mortality resulting from disease?
Counts
Ratio
a fraction with no specified relationship
Proportions
what fraction of the population is
affected
Rates
how fast things are occurring
Measures
Measures of morbidity
Prevalence: a proportion
Cumulative incidence: a rate
Incidence density: a rate
Measures of mortality
Mortality rate: a rate
Standardized mortality (SMR)
Defining case
Natural course of disease
Exposure onset symptoms dx outcome
Incubation Clinical Recovery
period Stage Death
Subclinical Chronic disease
Stage
Counts
Prerequisite for epidemiologic investigation
Simplest measure of disease frequency
Frequency of affected individuals
Useful for planning adequacy of health care
allocation at a particular level
For example:
Number of West Nile virus cases
Ratio
A fraction with no specified relationship between
numerator and denominator
Range: 0 to
A/B
Examples
sex ratio (M:F)
Ratio
Number of men with syphilis, 1991
2,412
Number of women with syphilis. 1991
2,314
Ratio of male to females
2,412/2,314 = 1.04
(The numerator is not included in the
denominator)
Proportion
Type of ratio
Numerator included in denominator
May be expressed as percentage
Percentage = proportion x 100 %
Range: 0 to 1
A/(A+B)
Example
Prevalence
Prevalence
All individuals with a disease at a given point in
time
Dimensionless - should not be described as a
rate - may be described as a percent
number of cases (A) today
P=
total population (A+B) today
Prevalence
Proportion of individuals in a population who
have the disease or condition of interest at a
specific time period
Utility
Describe health burden of a population
Status of disease in a population
Estimate the frequency of exposure
Project health care needs of affected
individuals
Types of prevalence
Point prevalence – proportion of all cases at a
specific point in time
Period prevalence – proportion of all cases
during a period of time
Point and period prevalence
Point prevalence
Do you currently have asthma?
Period prevalence
Have you had asthma during the last five
years?
Every person in the numerator had the
disease at some time during the period
specified.
Period prevalence consists of the point
prevalence at the beginning of a specified
period of time plus all new cases that occur
during that period.
Rate
A special type of proportion
Unit of time in denominator
A/(A+B) per time interval
Always two components:
New cases and time
Incidence
Incidence is an important rate…
It is the proportion of people (at risk) who
develop diseased during a specific time
period.
Three key elements:
Only new cases included in numerator
Total population at risk in the denominator
Time element – period over which new
cases developed
Two main types of Incidence:
Cumulative Incidence
Incidence Rate (a.k.a. incidence density)
Cumulative Incidence
One of the most widely used measures of
disease risk.
Estimate of probability (risk) that an individual
will develop disease during a specified period of
time
Cumulative Incidence =
No. of new cases in a given period of time
No. of people at risk during that time
Incidence rate (incidence density)
Cumulative Incidence gives each individual
equal weight, but different people stay in the
study for different length- having different
contribution.
Measure of the true rate of disease development
Incidence rate =
No. of new cases in a given period of time
Total person-time of observation
Person-time
ID 1/95 1/96 1/97 1/98 1/99 1/00 Total
A x 3
B 3
C x 5
D x 1
E x 4
Total years at risk 16
• = enter the study, X = having disease,
loss to follow-up
5-year (1/95-1/00) Incidence rate
= 3/16 = 18.8/100 person-years of observation
Prevalence vs. incidence
ID 1/95 1/96 1/97 1/98 1/99 1/00
A x
B
C x
D x
E x
• = enter the study, X = having disease,
loss to follow-up, disease developing
1/97-1/00 cumulative incidence cases: A, E
1/97-1/00 period prevalence cases: A, D, E
1/98 point prevalence: A, D
Relationship between
prevalence and incidence
Incidence is a proxy for “risk”, whereas
prevalence is best for assessing disease burden
or case load in a geographic area.
There is a well known relationship between them,
namely –
Prevalence = Incidence x Duration of disease
P = I x D
Whole population Whole population
at time t at time t +1
Plus incident cases
Prevalent
Prevalent
cases Prevalent
cases cases
Minus
cures or
deaths due
Prevalent cases to disease
Examples of P = I x D
If the incidence of diabetes mellitus is 1% per
year and its approximate duration is 5 years,
then what is its expected point prevalence?
Assuming equal incidence of disease, which
is more prevalent: pancreatic cancer or brain
cancer?
Average duration of pancreatic cancer = 3
months
Average duration of brain cancer = 1.5 years
Measures of mortality
Annual mortality rate from all causes =
Total no. of death from all causes in 1 year
No. of people in the population at midyear
Case-fatality rate =
No. of individuals dying during a specified
period of time after disease onset
No. of individuals with the specified disease
Three common forms of rates
Crude rates
e.g. crude birth rate, crude death rate
Specific rates
e.g. sex-specific, age-specific, race-specific
Adjusted rates
e.g. age-adjusted
Crude rate: example
Suppose County B recorded 4000 births and 1500
deaths in 1999. Using U.S. Census data, we find
that the population size is 200,000.
Crude birth rate =
No. of live births in time interval T
Total population
= 4,000/200,000 = 20 births per 1,000
Crude death rate =
No. of deaths in time interval T
Total population
= 1,500/200,000 = 7.5 deaths per 1,000
Specific Rates for Mortality in
Older Adults
Rates for selected leading causes of death among older adults, by sex,
and race -- United States, 1996*
Sex Race
Cause of death† Total Male Female White Black
Heart disease 1,808 1,983 1,686 1,820 1,937
(612,199)
Malignant neoplasms 1,131 1,442 915 1,125 1,338
(382,988)
Cerebrovascular diseases 415 374 443 412 479
(140,448)
* MMWR Dec 17, 1999 / 48(SS08);7-25
How do we compare rates
across populations?
Crude rates are not helpful because …
Populations differ in their age distributions
Populations differ in their racial distributions
Populations differ in their SES distributions
How do we compare rates
across populations?
We compare rates across populations by putting
them on an even playing field -
that is, we either standardize one population on
another or
we use an outside standard and adjust our
populations to that standard.
For our purposes, the most
important is age-adjustment
Two types of age-adjustment
Direct Method
Indirect Method (SMR = standard mortality
ratio)
Direct method: example
Population A Population B
AGE N Risk Cases N Risk Cases
<20 100 .1 10 500 .1 50
21-50 200 .2 40 200 .2 40
>50 500 .4 200 100 .4 40
800 250 800 130
CRUDE RISK = 250/800 = 31% 130/800 = 16%
Crude risk indicates different risks of disease
between populations.
But age-specific rates indicate similar risks.
Direct method: example
Using the total of the two populations as the
standard population
Population A Population B
AGE Std. Risk Cases Std. Risk Cases
pop. pop.
<20 600 .1 60 600 .1 60
21-50 400 .2 80 400 .2 80
>50 600 .4 240 600 .4 240
1600 380 1600 380
AGE-ADJUSTED RISK = 24% 250/800 = 24%
Direct method: example
Apply risks in population B to population A (using
population A as the standard population.
Population A Population B
AGE Std. Risk Cases Std. Risk Cases
pop. pop.
<20 100 .1 10 100 .1 10
21-50 200 .2 40 200 .2 40
>50 500 .4 200 500 .4 200
800 250 800 250
AGE-ADJUSTED RISK = 31% 250/800 = 31%
Direct method
What information is needed to calculate age-
adjusted death rate, using the direct method?
Standard population distributed by age
Age-specific death rates in study
populations
The actual value of an age-adjusted rate is
meaningless because it depends on the
choice of the standard population.
It is only meaningful in comparison to other
rates which have been adjusted by the same
method and the same standard population.
Indirect method
Apply rates from a standard population
to each age stratum in the study population
to obtain expected number.
This adjusted rate interpreted as:
the rate that would have been experienced by
the study population if their rates had been
similar to the standard population.
Standardized mortality ratio (SMR)
SMR =
Observed number of cases per time
Expected number of cases per time
SMR = 1
indicates observed is not unusual
SMR > 1.0
indicates morbidity (or mortality) exceeds
expected
SMR = 2.0 indicates two-fold increase
SMR < 1.0
indicates morbidity (or mortality) is less
than expected
SMR: example-
death in white miners
Est. pop. of Death rate in Expected Observed
white miners general pop. death death
Age (1) (2) (3)=(1)X(2) (4)
20-24 74598 12.26 9.14 10
25-29 85077 16.12 13.71 20
30-34 80845 21.54 17.41 22
35-44 148870 33.96 50.55 98
45-54 102649 56.82 58.32 174
55-59 42494 75.23 31.96 112
Total 534533 181.09 436
SMR = 436/181.09 = 2.41
SMR disadvantage
SMR produces a ratio instead of a rate. It gives
relative information but does not describe the
mortality in the population.
SMR depends on the choice of the standard
population.