EPID 600; Class 3

Measuring disease occurrence

University of Michigan School of Public Health

1
 Epidemiology and measurement
Measurement is central to epidemiology
Fundamental observations in epidemiology are
measures of the occurrence of illness

2
 Quantification in epidemiology
1.  Prevalence
2.  Risk (incidence proportion)
3.  Incidence rate
4.  Odds

3
 1. Prevalence (proportion)

Number of cases
at a specified
Prevalence =
time
Number of persons in
population

Specified time interval can be a ‘point’ or ‘period’ of time

EXAMPLES
14 adult men per 1,000 were HIV + in Tanzania in June 1995
27 adult men per 1,000 were HIV+ in Tanzania in 1995 4
 2. Risk (incidence proportion)
In epidemiology, risk applies to an individual and refers to the
probability that a person will develop a given disease
In epidemiology, risk is seldom measured at the individual level but
rather at the population level, hence, the risk measurement for agroup
is referred to as incidence proportion

Number of new cases of disease over a

Risk = time
Number of persons followed period

5
 Example, risk
Fixed population: 1000 people observed for 5 years
When people become ill, assume all become ill on the last day of the time period

0.5 years 3 sick 1.0 years 5 sick

1.5 years 4 sick 2.0 years 3 sick

2.5 years 3 sick 3.0 years 5 sick

3.5 years 1 sick 4.0 years 2 sick

4.5 years 3 sick 5.0 years 4 sick

967 people never became ill

Therefore, Risk = # sick/total pop = 33/1000=0.033 6
 Risk, examples

Voluntary risks Risk of death per person per year

Motorcycling 1 in 50
Smoking a pack a day 1 in 200
Taking contraceptive pills 1 in 5,000
Legal abortion, >12 weeks 1 in 5,900
Drinking 1 bottle of wine/day 1 in 13,300
Playing soccer 1 in 25,500
Canoeing 1 in 100,000
Skiing 1 in 430,000

7
 Different risk patterns over time

Morbidity A Morbidity B
Annual risk of morbidity

Age 8
 Two key notions in stating and
interpreting risk

Risk is meaningless without a time interval

e.g., “Risk of death from cardiovascular disease among
women 60 years of age is 2%”...means what?
Competing risks make it difficult to use risk as the only
assessment of disease occurrence in a study although this
can be done in studies where follow-up is short and
competing risks are low; e.g., Salk vaccine trial in children

9
 3. Incidence rate
One solution to dealing with competing risk problem faced
by incidence proportion is to consider incidence rates
Incidence rates are concerned with the number of new
cases during a particular person time of follow-up
In some cases, e.g., national mortality rates, time period is
taken as mid-point of a specific interval (i.e., mid-year)

10
 Incidence rate

Number of new cases

Incidence Rate =
Total time at risk of persons followed

EXAMPLE
20 new cases of HIV infection during 8,000,000 person
years of follow-up, that is, among 8,000,000 persons
followed-up for 1 year 11
 Understanding person-time

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 TT

P1

P2

P3

P4

P5

P6

P7

P8

P9

P10

12
 A person-time example

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 TT

P1 14

P2 20

P3 11

P4 11

P5 20

P6 20

P7 10

P8 20

P9 2

P10 10

13
 An example

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 TT

P1 14

P2 20

P3 11

P4 11

P5 20

P6 20

P7 10

P8 20

P9 2

P10 10

14
 Therefore

Assume lightning bolt is disease onset

1
Pr evalence at T11 =
7
3
Risk = new cases over a given time period
10
3 3 new cases
Incidence rate = =
14 + 20 + 11 + 11 + 20 + 20 + 10 + 20 + 2 + 10 138 person time

15
 Example, Incidence Rate
Fixed population: 1000 people observed for 5 years
When people become ill, assume all become ill on the last day of the time period

0.5 years 3 sick 1.0 years 5 sick

1.5 years 4 sick 2.0 years 3 sick

2.5 years 3 sick 3.0 years 5 sick

3.5 years 1 sick 4.0 years 2 sick

4.5 years 3 sick 5.0 years 4 sick

967 people never became ill

Therefore, IR= # sick/PYO = 33/[(967*5)+(3*0.5)+...etc]=33/4,921=6.7/1000 PYOs
16
Another way to think of incidence and
prevalence

Incidence

Prevalence

17
Another way to think of incidence and
prevalence

Incidence

Prevalence

18
Another way to think of incidence and
prevalence

Incidence

Prevalence

factors affecting prevalence include

incidence, duration of disease,
death rates

19
Factors leading to increased prevalence
Increased incidence rate
Increased duration of disease, e.g., prolonged
survival
More case finding, e.g., screening
Lower mortality

20
 number of cases per 100,000 population

time
HIV Prevalence and Incidence
Comparing incidence and prevalence

21

number of new cases per 100,000 population

per year
 Notes about prevalence and incidence
Prevalence represents the number of cases among persons of interest
at a given point in time
Therefore, prevalence is not a rate; the term “prevalence rate” should
not exist
Incidence (including both incidence proportion and incidence rate)
represents number of new cases over a particular person-time of
follow-up
Therefore risk (incidence proportion) and incidence rate both are not
meaningful without a time unit
Always be as specific as possible when articulating units of
measurement...what are you measuring? among who? over what time
period?

22
 Comparing prevalence, risk (incidence
proportion), and incidence rates

  Risk and prevalence range from 0 to 1

  Incidence rate ranges from 0 to infinity

23
 Issues in measurement of incidence and
prevalence

Think of numerator and denominator

How do we know something is a “case”?
How do we count population “at risk”?
What is a specific “time period”?

24
 Interrelations among measures (1),
incidence proportion and incidence rate

Risk = Incidence rate x time

[0-1] [0-∞] [0-∞]

This is only applicable where risk is low (<20%?)

25
 Example, incidence proportions and rates

Population of 1,000 persons

Mortality rate of 11 deaths per 1000 person years over a 20
year time period
Therefore, Risk = [11/1000]*20 year = 0.22
So, risk is that among 1000 people there would be 220
deaths (22%) over the 20 years
This ignores population change or possible addition or
removal of population from follow-up

26
 Interrelations among measures (2),
prevalence and incidence rate

IR * D = P
1–P

This applies only in “steady state”, where incidence rates

and disease duration are stable over time

27
 And....

P
= IR * D
1− P
therefore
P = ( IR * D) *(1 − P)
P = IR * D − IR * D * P
P + IR * D * P = IR * D
P(1 + IR * D) = IR * D
IR * D
P=
1 + IR * D
28
 Therefore, prevalence and incidence
rate

IR * D = P
1–P
if p <0.10, then 1-P ~1
Therefore, for low prevalence (and steady state),

IR * D ≅ P

29
 4. Odds

probability, risk

p
odds =
1− p
30
 Interpreting odds
Odds = p/(1-p)
Therefore, if probability is 0.75, odds are
0.75/(1-0.75)=0.75/0.25=3
Note that 3:1 odds means that a horse has a 75%
probability of losing a race
Good odds, if this is a horse race, are 1:1, that is,
probability is 0.50 and odds are 0.50/(1-0.50)=1; this then
means that a horse has a 50:50 chance of winning or losing

31
 Annual mortality rate

Annual # of deaths in 1 year

mortality = x 1000
# of persons in population
rate
at mid-year

Notes
  Multiplication by 1000 is by convention 32
 Case fatality rate

Case total # of deaths

fatality = x 1000
rate # of persons with a disease

Notes
  Multiplication by 1000 is by convention
  The time period here is implicit as the time for persons with disease, presumably
low
  For diseases with low fatality, survival measures are better used 33
 Attack rate

total # of new persons with disease

Attack
= x 100
rate
# of persons at risk of disease

  Note: the time period here is implicit as the time for persons with
disease, presumably low
  For diseases with low fatality, survival measures are better used
34
 Some examples
Is the prevalence of osteoarthritis in the population low or high?
Is the annual mortality rate from osteoarthritis low or high?
Is the annual mortality rate from respiratory anthrax low or high?
Is the case fatality rate from respiratory anthrax low or high?

35
 Measuring Tuberculosis
Recap...some reasons why accurate measurement is
important
To define public health needs
To assess how well we are doing at addressing those needs
A review of measurement issues in the context of the global
TB burden was published in the Lancet in April 2008

36
Dye et al. Lancet. Measuring tuberculosis burden, trends, and the impact of control programmes. 2008; 8: 233-243.
 Measuring Tuberculosis trends

37
Dye et al. Lancet. Measuring tuberculosis burden, trends, and the impact of control programmes. 2008; 8: 233-243.
 Measuring Tuberculosis trends

“incidence”
over time by
country

38
Dye et al. Lancet. Measuring tuberculosis burden, trends, and the impact of control programmes. 2008; 8: 233-243.
 Measuring Tuberculosis trends

Prevalence estimates

39
Dye et al. Lancet. Measuring tuberculosis burden, trends, and the impact of control programmes. 2008; 8: 233-243.
 Measuring Tuberculosis trends

Problems: Plausibility of measured distribution

Cases/suspects
Fluctuations in reported cases
40
Dye et al. Lancet. Measuring tuberculosis burden, trends, and the impact of control programmes. 2008; 8: 233-243.
 Measuring Tuberculosis trends

Problems: Plausibility of measured distribution

Cases/suspects
Annual fluctuations in reported cases
41
Dye et al. Lancet. Measuring tuberculosis burden, trends, and the impact of control programmes. 2008; 8: 233-243.
 Final notes (1), expressing prevalence
and incidence
Prevalence often expressed as cases per 100,000
Incidence rate is also sometimes expressed as per 100,000
but this is wrong since needs time dimension (per year?)

42
 Final notes (2), other terms for
measures of disease occurrence
Frequently we see “period prevalence” referred to, which
refers to prevalence measured during a time period (e.g.,
one year)
Cumulative incidence is sometimes used to measure the
incidence of disease during a given time period divided by
population at risk; this is the same as incidence proportion
Incidence density is sometimes used instead of incidence
rate to refer to computations that use person-time; this is
identical to incidence rate discussed here

43
 Summary of measures of disease
frequency

Prevalence Risk Incidence rate Odds

Number with Number with Number with

Numerator Risk
disease new disease new disease

Total number
Total number of people at Person years
Denominator 1-Risk
of people risk at at risk
baseline

At a point in Over a time Over a time Over a time

Time
time interval interval interval

44