Measures of disease frequency

BM Hamooya
Learning objectives
• Differentiate the following measures: counts, rates, ratios, prevalence,
incidence, and odds

• Calculate the following measures of disease frequency: Rates, ratios,

prevalence, incidence, and odds

• Define the concept of person-time and applicability in the calculation of

rate

• Choose the appropriate measure of frequency for a given situation

• Interpretation of the measures of disease frequency within the context of

public health research
Recap
• Definition of epidemiology
ü“The study of the distribution and determinants of health-related states or events
in specified populations, and the application of this study to the prevention and
control of health problems”

• The epidemiological approach

üDescriptive (asking question)
üAnalytical (making comparisons)

• The aims of epidemiology

üDescribe disease-distribution, frequency
üIdentify etiology factors
üProvide data for planning and implementation and for priority setting
Measures of Disease Frequency
• Measures of disease frequency: the ability to quantify the number of
individuals with a particular health outcome.
• They basically calculate the magnitude of disease occurrence.

1. Count: number of individuals meeting the case definition;

• Ex: Number of cases of cervical cancer in Southern Province of
Zambia in 2010 (Cancer Registry data)

• Count is simple to derive and

• It can be used for allocation of health resources.

2. Proportion:

• A/(A+B)
• Fraction in which numerator (A) is necessarily part of the denominator
• Numerator (A) includes only individuals who meet the case definition (cases)
• Denominator (A+B) includes cases and non-cases
• Always ranges from 0 to 1
• A proportion is not dependent upon time. A proportion indicates the fraction of
the population that is affected by the disease or condition. It is linked to
estimating risk.

• Often expressed as a percentage (Proportion x 100)

• Ex. 50% of persons 50 years and over have been screened for colon cancer in
Kampala
• 30% of individuals in Livingstone have HIV
• Ex: Calculating the proportion of women with cervical cancer requires a
special consideration. Cervical cancer only occurs in women with a
cervix. A woman who has had a complete hysterectomy is no longer are
at risk for developing cervical cancer. This is a large segment of the
population of older women. The National Women’s Health Information
Center of the US Department of Health and Human Services reports
that 1 in 3 women have had a hysterectomy by age 60. Thus, women
with hysterectomies are not included in the denominator when
calculating the proportion of women with cervical cancer as part of the
population at risk.
3. Prevalence (P)
• Proportion of population with existing cases (of disease/event)
at a given point or period of time
• Point prevalence: proportion of population with existing cases in at a
given point in time (t)
• Period prevalence: proportion of population with existing cases in a
during a period of time

Number of existing cases

Prevalence =
Total population

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• Example: Calculate the prevalence of tungiasis in the MPH class on
September 24th, 2013.
• 14 MPH “officers” with tungiasis on September 24th, 2013
• Total population of the MPH class is 100

Number of existing cases

Prevalence =
Total population

14
Prevalence =
100
Prevalence = 0.14 0r 14% on September 24th 2013

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 Example of Point and Period Prevalence and
Cumulative Incidence in an Interview Study of Asthma

• “Do you currently have asthma?”

• Point prevalence

• “Have you had asthma during the last 5 years?

• Period prevalence

• “Have you ever had asthma?”

• Cumulative incidence
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A proportion is necessarily not a “rate”

• You will see these terms mixed up in epidemiologic and

scientific literature

Let’s not do that!!!

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Factors that Increase Prevalence

• Long Duration
• Low cure rate
• Low case fatality
• Increase in New Cases
• Improved Detection
• Immigration of Patients
• Emigration of Healthy People

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Factors that Decrease Prevalence

• Short Duration
• Decrease in new cases
• Improved cure rate
• Emigration of patients
• Immigration of healthy people

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Uses of prevalence
• Estimate the magnitude of health/disease problems in the
community and identify potential high-risk population groups.

• Assessing the need for preventive action, healthcare and the

planning of health services.

• Prevalence is a useful measure of the occurrence of conditions

for which the onset of disease may be gradual e.g hypertension,
diabetes or rheumatoid arthritis.
• Disadvantages of prevalence: they do not usually provide
strong evidence of causality
4. Ratio: A/B; a special fraction in which the numerator includes only
individuals who meeting one criterion (e.g. the case definition) and the
denominator includes only individuals in the study population who meet
another criterion (e.g. do not meet the case definition but are at risk). A
ratio is not dependent upon time. A ratio as a measure of disease
frequency is used infrequently, in special situations. (not to be confused
with an odds-ratio or risk-ratio)

• Ex: 1 case of colon cancer for every 1 case of breast cancer.

• Ex: 2 female cases of major depression to 1 male case of major
depression.
• The next two measures also have a time factor.
• Ratio: (A/B)
• Fraction in which the numerator is not necessarily part of the denominator
• Allows for comparison of quantities that may be of a different nature

• Examples:
• Sex Ratio: Female to Male Ratio: in SPH?
• Number of Participants per facilitator: 8/1
5. Rate: Measures the occurrence of some particular outcome
(development of disease or the occurrence of death) in a population
during a given period of time.
va fraction in which the numerator includes only individuals who meet
the case definition and the denominator includes individuals in the
study population who do or do not meet the case definition but could
meet the case definition (at-risk).
vA rate is dependent upon time.
vIn other words, a proportion over a particular period of time.
vAn epidemiologic rate will contain the following: disease frequency
(numerator), unit of population size, the time period during which the
event occurred and multiplier.
• Ex: 44 cases of colon cancer per 100,000 population in Lusaka during
2012.
• A rate is expressed per 1000 or some other round figure like 100,000
• Rate: A/((A+B)*time)
• Proportion over a particular period of time
• Measures the speed of occurrence of health events

• Contains
• Disease frequency (numerator = number of events observed for a given time)
• Population Size
• Time Period during which the event occurred
6. Risk: the probability of an individual meeting the case definition
(person-time rate). Risk is dependent upon time.
• Ex: 0.00044 colon cancer cases per person-year (typically derived from
a cohort study in which each at-risk person is followed over time until
he/she is no longer at-risk).

• Cumulative incidence = Risk

Cumulative Incidence (CI)
• Incidence: the rate at which new events occur in a population

• CI: Number of new cases that develop in a population at risk

during a specified time period

• Population at risk = source population

• Susceptible population
• Must be free of disease
Cumulative Incidence (CI)
• Proportion of a population who develop a health-related event during
a specified time period

Number of new cases

CI =
Total population at risk

Over a specified period of time

• Often expressed as the incidence per 1,000 persons, or 10,000
persons, or 1 million persons

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Cumulative Incidence (CI)
• Two critical points
• Incidence is the new cases of disease. Any individual who is in the
denominator must have the potential to become part of the group who
is counted in the numerator, and must be free of disease at the
beginning of the assessed time period

• The time period must be specified. One can calculate the 1-month
incidence, the 1-year incidence, the 10-year incidence

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Cumulative Incidence (CI)

• For cumulative incidence to be accurate:

• Fixed population
• Entire population is followed for the entire follow-up period
• All first events are detected
• The duration of disease does not change over the follow-up period

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Cumulative Incidence (CI)
• Example: Calculate the CI of tungiasis occurring among MPH
students from September 24th, 2013 to December 24th, 2013

• 100 students free of tungiasis enrolled as of 24/11

• 20 cases of tungiasis detected over the 3 months
Number of new cases
CI =
Total population at risk
20
CI =
100
0.2 over 3 months or 20% over 3 months
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Cumulative Incidence (CI)

• Directly estimates Risk

• Risk: probability (p) that the event will occur in the specified
time interval, conditional on remaining “at risk”

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 €€€
€ €€ Defined population

€€€€€€
€€
€ €€€ Prevalent cases

€€
€ €€€
Prevalence

=Number of cases
Total population
€ €
Diseased Non-Diseased =4/24
=16.7% 27
After 10 years following up the non-diseased
Incident/New
cases

€€€
€ €€ Risk

€€€€€€ =Number of new cases

Total population at risk
=4/20

€€
€ €€€ =20% over 10 years

€€
€ €€€ Incidence rate
(assume illness occurred
at the end of 10 yrs)
=Number of new cases
Total PYO
=4/200

€ €
Diseased Non-Diseased
€ New /incident
disease cases
=20/1000 PYO
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Odds

• Odds p/(1-p):
• Probability of event/ probability of non-event

• Example:
• Risk = 0.10
• Odds = 0.10/0.90 = 0.11

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