Frequency Measures: Morbidity: Classical Epidemiology 623

Frequency Measures: Morbidity
Classical Epidemiology 623
Learning objectives
• The students should be able to:
– Define health & morbidity
– Perform basic morbidity calculations
– Express morbidity data in various forms
– Interpret morbidity data
What is health?
“ Health is a state of complete physical,
mental and social well‐being and not merely
the absence of disease or infirmity”
(WHO, 1948)
Measuring Disease Occurrence:
Morbidity & Mortality
Comparing Disease Occurrence:

Risks
What is morbidity?
Any departure, subjective or objective, from a
state of physiological or psychological well‐
being. In this sense sickness, illness, and
morbid condition are similarly defined and
synonymous.
How would you express morbidity
information?!
“When you can measure what you are talking
about and express it in numbers, you know
something about it.”
Kelvin
Cutaneous leishmaniasis in the West
Bank
• No of new cases: 237
• Males 130, females 107
• Male to female ratio 1.21:1.00
• Total population:2, 367, 550
• Incidence rate: 10 per 100,000
• Prevalence rate: 25 per 100,000
* Numbers and rates in this slide does not reflect reality
Modes of summarizing data
Count numbers: N only

Proportions and risks: N/D
Ratios: N/D
For all summary measures, one needs to

specify time, place and persons (population
of study)
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.
Count = number of events
 Examples:
400,000 diabetic cases in 2018 in country A with

a population of 4.0 million
4,000,000 diabetic cases in 2018 a country X

with a population of 40 million
 Influenced by size of population (range 0+)

Proportions
 Proportion = number of events divided by the
population from which the events occurred
400,000 diabetic cases = 0.1 (10.0%) in A in 2016

4,000,000 population
4,000,000 diabetic cases= 0.1 (10%) in country X in 2016

Proportion is multiplied by a constant 10x (k) value as appropriate
2,000 AIDs cases = 0.0005 = 5 per 10,000

Proportion (cont’d)
 A proportion is the expression of one part to the
whole: a/a+b
 Numerator: people with the disease, condition or
event
 Denominator: all people (with and without the
disease, condition or event)
 Numerator is always included in the denominator -
females/(females + males)
Ratio = number of events divided
by another number
West Bank pop/ Gaza Strip pop=2,367,550/1,370,345
Ratio = 1.73:1.00
Range?
Ratio (cont’d)
 A ratio is defined as a part divided by another

part: a/b
 Numerator: People with the disease, condition or
event
 Denominator: People without the disease,
condition or event
 Numerator is not included in the denominator -
females/males
Relation between ratio and proportions
Ratio = a a= (a/a+b) a = (proportion)

b (b/a+b) (1- proportion)
Proportion = a a= (a/b) a = (ratio)

a + b (a + b)/b (ratio + 1)
Example
The percentage of males among the diabetic cases in Lebanon
is 70%  M/F ratio (.7)/(1-.7) = .7/.3 or 7/3 or 2.33 to 1
If the M/F ratio was 7 to 1, what is the proportion of males? of
females?
Measures of Morbidity
 Incidence
 Prevalence
1. Incidence= (N/D) * k
Incidence measures the rate at which people without

the disease gets the disease during a specified
period of time. It is a measure of risk of occurrence
of new cases.
no. of new cases occurring in the population during a specified time period X 10x
no. of persons at risk of developing the disease during that time period
Examples:
Crude cancer incidence in the West Bank in 2014:
(2294/2,790,755) x 100,000 = 82.2 per 100,000
Sex-specific cancer incidence assuming equal male/female

population size!:
 Male specific cancer incidence in the West Bank in 2014
(1162/1.395 mil) x 100,000 = 83.3 per 100,000
 Female specific cancer incidence the West Bank in 2014
(1132/1.395 mil) x 100,000 = 81.1 per 100,000
Specification of time and place

Cancer Incidence for 1998-2002
by District West Bank
District INCIDENCE / 100,000
1 Bethlehem 87
2 Nablus 70
3 Ramallah 63
4 Hebron 62
5 Tulkarim 58
6 Jericho 55
7 Jenein 53
8 Salfeit 45
9 Qalqeilia 38
10 Jerusalem 8
Is this Incidence or Prevalence?
Attack rate
Attack rate: is incidence rate when exposure and

disease are of limited duration, as in an epidemic
Primary attack rates: . initial cases .

population at risk
Secondary attack rates: all cases - initial cases

population at risk
Example:
In the first month of the SARS outbreak, a total of
100 cases were detected (60 males) This
epidemic occurred in a community of 1,000
individuals (500 males). What is the overall attack
rate and sex-specific rates? What is the
proportional distribution of the cases by sex?
What is the secondary AR knowing that in the
second month 180 new cases were detected in
the same community?
2. Prevalence = (N/D) * k
Prevalence measures the number of people in a
population who have the disease (new and pre-
existing) at or during a given point in time.
Point prevalence: at Period prevalence: during
new and pre-existing cases at/during a specified time period X 10x

no. of persons at risk of disease during that time period
Example: Inan interview survey
conducted in a sample of 1000 BZU
students, 400 reported smoking at least
one cigarette during the past year. For
100 students, it was their first attempt.
What is the best estimate of the
prevalence of smoking at BZU? What
about incidence?
Incidence vs. Prevalence
Question Cases Measure

Do you currently have HBP? 80
During the past n (one) year(s), 150

have you had HBP?
How many of above cases, were 50
new cases which developed
during the past year?
More examples
Jan 1, 2015 June 30, 2015
A
B
C
D
E F
G
H I
 Point prevalence on Jan 1? On June30?

 Incident cases between Jan and June?
 Period prevalence between Jan and June?
Period prevalence: Point prevalence at beginning of
period + incident cases during that period
Incidence vs. Prevalence again
 Prevalence is a function of both incidence and duration of
the disease.
 P = I x D (when I and D are fairly stable)
 Diseases with relatively low incidence such as

diabetes can have relatively high prevalence, if the
disease duration is long.
 Common diseases (e.g., head lice) can have moderate
or low prevalence, if duration is short.
Characteristics of Prevalence
 Prevalence measures cause and effect simultaneously
Impossible to infer causation
 Useful for planning (e.g. beds, clinics, workforce needs)
 Relatively easy to obtain  need only 1 measurement at
one point in time
 High prevalence  high risk
could reflect increased survival (improved care, long
duration, large influx of migrants at high risk for
disease)
 Low prevalence  could reflect rapid fatal or cure process
- short duration, improvement in treatment)
What are DALYs?
Now, let’s go for the acid test!
Did we learn new concepts,
methods, or skills?
Question 1
Of 20,000 middle‐aged men (with no previous
myocardial infarction), 60 developed a
myocardial infarction during a 6‐month period of
follow up.
What measure of myocardial infarction during this
6‐month period can be computed?
Compute and interpret?
Question 2
Table below shows the number of cases of hepatitis E
diagnosed in each of Jericho and Kobar.
Which one has the highest incidence of hepatitis E?
Please note that this data is hypothetical
City New cases of Year Population

hepatitis E
Jericho 68 2012 28,500
Kobar 32 2012 5,750
Question 3
What is the effect of a new well developed modern
specialist center that offer curative treatment for
sufferers of a previously incurable disease on the
following?
(i) the incidence,
(ii) the prevalence and
(iii) the duration of the disease.
State clearly any assumptions that you make.
Question 4
What is the effect of a new drug on the
prevalence, incidence and duration of diabetes,
if the new drug is effective in reducing the
complications of diabetes and improves the
survival, but does not cure diabetes?
Question 5
What is the effect of a new HIV/AIDS drug that
is very effective in prolonging the survival but
does not cure, on the prevalence, incidence
and duration?
Question 6
A rapidly killing new flu infection
Prevalence ???
Incidence ???
Duration ???
Factors that increase Factors that decrease
prevalence prevalence
Important sources
• Bonita R, Beaglehole R, Kjellstrom T, 2006. Basic

Epidemiology. Geneva: WHO.
• Gordis L, 2009. Epidemiology, 5th ed. Philadelphia:
Elsevier Saunders.
• Last J, 1995. Dictionary of Epidemiology. New York: OUP.
• MOH annual reports 2014 and 2019
• Some slides were extracted with permission from a
presentation prepared by Prof Abla Sibai.
• Some slides were extracted with permission from a
presentation prepared by Dr. Lukman Thalib.

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Frequency Measures: Morbidity

Comparing Disease Occurrence:

Count numbers: N only

For all summary measures, one needs to

400,000 diabetic cases in 2018 in country A with

4,000,000 diabetic cases in 2018 a country X

 Influenced by size of population (range 0+)

400,000 diabetic cases = 0.1 (10.0%) in A in 2016

4,000,000 diabetic cases= 0.1 (10%) in country X in 2016

Proportion is multiplied by a constant 10x (k) value as appropriate

2,000 AIDs cases = 0.0005 = 5 per 10,000

West Bank pop/ Gaza Strip pop=2,367,550/1,370,345

 A ratio is defined as a part divided by another

Ratio = a a= (a/a+b) a = (proportion)

Proportion = a a= (a/b) a = (ratio)

Incidence measures the rate at which people without

Sex-specific cancer incidence assuming equal male/female

Specification of time and place

Attack rate: is incidence rate when exposure and

Primary attack rates: . initial cases .

Secondary attack rates: all cases - initial cases

Point prevalence: at Period prevalence: during

new and pre-existing cases at/during a specified time period X 10x

Question Cases Measure

During the past n (one) year(s), 150

 Point prevalence on Jan 1? On June30?

 P = I x D (when I and D are fairly stable)

 Diseases with relatively low incidence such as

City New cases of Year Population

• Bonita R, Beaglehole R, Kjellstrom T, 2006. Basic

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