Subject: COMMED Topic: Measures of Disease Frequency Association Lecturer: Prof.

Danaida Marcelo Date of Lecture: June 29, 2011 Transcriptionist: pinkyred Pages: 10

REVIEW Epidemiology concerned with the distribution and determinants of disease frequency in human populations y disease - health-related events -- chronic disease, environmental problems, behavioral problems, and injuries in addition to infectious disease. 5 D s diseases, deaths, disability, destitutions, dissatisfaction characterizes health events in terms of o Time o Place o Person disease frequency o example : Ratio, Proportion, Rate y In epidemiology, the measures of disease frequency are in the forms: o Ratio o Proportion o Rate

y y

RATIO y Expresses the numerical relationship between two quantities which may or may not be related with each other Follows the form:

number of breast cancer in countries A and B y

Example:

Given: In TB-DOTS Center X, in Jan1- Dec31, 2009 450 patients (215 males, 235 females) What is the sex ratio of patients?

* country B has bigger frequency of women having breast cancer (75/5000 =0.02 or 2 per 1000) compared to country (A 100/50000)

MEASURES OF DISEASE FREQUENCY Three factors to consider when measuring disease frequency 1. the number of people with the disease/outcome 2. the size of the population (where people with the disease/outcome are members) 3. the length of time the population were observed

Other examples: o Dependency Ratio (indicator for population aging) o Ratio of Health Worker to Population (indicator for adequacy of primary health care coverage) o Ratio of Hospital Beds to Population- numerator not part of denominator o *A and B should occur for the same specified geographic area and the same period of time.

Special type of ratio:

SY 2011-2012

y y

numerator is part of the denominator Follows the form:

where A is part of B y Expressed in percentage y Other epidemiologists - Proportion that has time dimension; defined by time, place and person

PROPORTION y example

Given: In TB-DOTS Center X, in Jan1- Dec31, 2009 450 patients (215 males, 235 females) What is the proportion of male patients in TB-DOTS Center X?

Example: 500 new students in Maunlad College of Medicine were negative on PPD testing on Jun1, 2009. In June 1, 2010 after re-testing: 4 students converted from (-) to (+) PPD. What is the PPD conversion rate from June 2009-2010?

=48% y example MEASURES OF DISEASE FREQUENCY Given: In Municipality Y, Jan1- Dec31, 2009; 20 TB deaths, 145 deaths from other causes. What is the proportionate mortality ratio for TB? Incidence and Prevalence Two Basic Types y Incidence o Cumulative Incidence o Incidence Density Prevalence o Point Prevalence o Period Prevalence

RATE y y y y has time dimension Also a proportion Measures the occurrence of an event in a population over a given interval Epidemiologists consider a measure as a rate if time is an integral part of the denominator (true rate)

PREVALENCE y Indicates proportion of individuals in a population who have a particular disease or condition at a specified point in time or period of time Cases are counted in prevalence until they recover or die Expressed in % (*100) Appropriate for stable and chronic conditions

y y y

Example: Incidence Density or Incidence Rate (unit of measurement: person-time)

Point prevalence y y Proportion of the population who has the disease at a single point in time Since examination is done at a single point in time, it may be an underestimate

*If this is printed in black and white, the lines B, E, G, I and J are highlighted.

Period prevalence y The proportion of the population who has the disease at any time during a particular time period Time period: day, week, year, etc. *prevalence denominator is the number of population

y y

example: Given N=100; 1.) What is the period prevalence from Aug1 to Oct1?

3.) What is the point prevalence of Disease X on Oct 1, 2009?

*If this is printed in black and white, the lines B and H are highlighted

2.) What is the point prevalence of Disease X on August 1, 2009?

INCIDENCE y Indicates the development of new cases of a disease in a population during a specified period of time Estimates the risk of developing a disease in the population during the specified time period

y y

Denominator includes all people who are at risk at the start of the time period of interest Appropriate for acute illnesses When reporting and comparing incidence, note: o the constant that was used (i.e., 102, 103, 104, 105) o the time period o the population that was studied

example:

N=10 persons observed for a period of 12 years; Persons A, C, I got sick

Cumulative Incidence (CI) y y y Appropriate when the population at risk is fairly constant, fixed aka incidence risk Assumes that all people in the population contributed the same amount of time to the measure

*If this is printed in black and white, lines A, C and I are highlighted

example:

Given: 20,000 population in Bgy. Maunlad were TB infection- free at the start of the year 2009; 30 new cases of TB from Jan 1 - Dec 31, 2009. What is the cumulative incidence of TB in Bgy. Maunlad in 2009?

=0.0015 =1.5 per 1000 ~ 15 per 10000

MEASURES OF DISEASE FREQUENCY Most Common Measures of Disease Frequency in Public Health y Mortality Rates o incidence measure where outcome is death o Crude o Specific Morbidity Rates o incidence or prevalence

Incidence Density (ID) y y Appropriate when the population at risk is dynamic or changing Denominator is the total time period that each person is observed: person-time at risk Person-time units: days, months, years, etc.

CRUDE DEATH RATE

y y

Rough estimate occurrence of death due to all causes in a particular population during a specified period of time

Other groupings

y y example:

example:

Given: 451,740 total deaths in the Philippines in 2008. The estimated mid-year population in 2008 was 90,348,000

Given: 51,811 deaths among women in 2005. Mid-year population of women was 44,757,304

*Care when comparing with populations with different population structure

CASE FATALITY RATE y y y Killing power of a disease Measures the risk of dying from a particular disease Expressed in %

CAUSE-SPECIFIC MORTALITY RATE y y measures the rate of dying from a specific cause of death crude rate

example:

Given: 27,557 deaths due to TB in the Philippines in 2000; 126,489 cases of TB during the same period y example:

Given: 32,000 tuberculosis deaths in the Philippines in 2009. The estimated midyear population in 2009 was 97,976,603

*influenced by incomplete reporting of both deaths due to the particular disease and morbidity rate

PROPORTIONATE MORTALITY RATIO y shows the numerical relationship between deaths due to a particular cause and the total numbers of deaths due to all causes

SPECIFIC MORTALITY RATE y measures the occurrence of death in a particular population during a specified period of time Age- specific mortality rate Gender- specific mortality rate

y y

Given: 27,557deaths due to TB in the Philippines in 2000; total number of deaths during the same period was 366,931 5

often used as an overall index of health status (per 1000 livebirths)

*Care should be taken when comparing PMR

UNDER FIVE MORTALITY RATE y a leading indicator of the level of child health and overall development in countries. Probability of a child born in a specific year or period dying before reaching the age of five (WHO definition) *Infant mortality rate improved in 2006 and target is likely to be attained by 2010

NEONATAL MORTALITY RATE y y Denominator- # of live births in a specified time and period Measures a ratio y Neonatal deaths account for a large proportion of child deaths. Mortality during the neonatal period is considered to be a useful indicator of maternal and newborn health and care. (WHO) Number of deaths during the first 28 completed days of life per 1000 live births in a given year or period. (WHO definition) incidence

Africa has the highest under five mortality rate per 1000 live births

INFANT MORTALITY RATE y y often used as an overall index of health status more common measurement

MATERNAL MORTALITY RATE/RATIO y Indicator of progress of a nation in providing adequate nutrition, and medical care for pregnant women

Per 100,000 livebirths

ATTACK RATE y y y Maternal mortality rate though slightly improving, might not reach the target by 2010 y another measure of morbidity Special measure of incidence Calculated for a small, defined population that is observed for a short, limited time Usually expressed in %

MORBIDITY RATE y number of new or existing cases of a particular disease or condition per 10n population can be a prevalence or incidence morbidity is a general word that can apply to a disease, condition, or event.

example:

Given: 500 people attended the party 90 had food poisoning What is the food with the highest attack rate? Food # who ate the food # who got ill among those who ate the food 40 50 Attack rate

y y

Examples: y Tuberculosis prevalence rate per 100000 (G6.T8.I23a): Proportion of tuberculosis (TB) cases (smear positives estimated) of all agegroups per 100000 population in a given year (WHO) Malaria prevalence rate per 100,000 population (G6.T8.I21a): Proportion of notified (clinically identified) cases of malaria per 100000 population in a given year. (WHO)

Carbonara Pansit palabok Spaghetti Pansit bihon

65 450

61.54% 11.11%

140 320

60 70

42.86% 21.88%

answer: CARBONARA (40/65*100=61.54%)

MEASURES OF DISEASE FREQUENCY SUMMARY

y y

y y

Calculated as Ratio, Proportion, Rate Two Basic Types o Incidence (Cumulative Incidence, Incidence Density) o Prevalence (Point Prevalence, Period Prevalence Mortality Measures Morbidity Measures = 1: noassociation MEASURES OF ASSOCIATION <,> 1: with association MEASURES OF ASSOCIATION RISK RATIO y Risk Ratio(Relative Risk) risk of developing a disease (outcome) in a group of people who were exposed to a risk factor relative to a group who were not exposed to the risk factor

Epidemiology concerned with the distribution and determinants of disease frequency in human populations Descriptive and analytical y y Descriptive-Measures of disease frequency Analytical-Measures of association (for determining factors associated with disease or health outcomes)

Relative Measures y y y y y y Prevalence Ratio-cross sectional studies Risk Ratio cohort studies, experimental or clinical trials Odds Ratio-case control study Absolute Measures-clinical trials,expt studies Risk Difference (Absolute Risk Reduction) Attributable Risk

RELATIVE MEASURES BASED ON STUDY DESIGN

2 x 2 TABLE y binary outcome, or with 2 category, exposure factor and outcome variable

example:

Research Question: Are women who are undergoing in-vitro fertilization more likely to suffer a miscarriage in the first trimester if they have bacterial vaginosis?

example:

Research Question: Is there an association between Obesity and having regular physical activity among women?

*Those women undergoing in vitro fertilization who had bacterial vaginosis are twice (1.95) more likely to suffer a miscarriage compared to those who didn t have bacterial vaginosis.

PREVALENCE RATIO *Among women: the probability of obesity among those with regular physical activity is 0.57 times less compared to those with not regular physical activity. ODDS RATIO y y y estimates the Risk Ratio if disease (or outcome) incidence is small (i.e. disease is rare, i.e. incidence <1 or <5%) appropriate measure of association for case-control studies

MEASURES OF ASSOCIATION SUMMARY Relative Measures of Association y y y Relative Risk (for Cohort, Clinical Trials) Odds Ratio (for Case-Control Studies) Prevalence Ratio (for Cross-sectional Studies)

Interpretation:

example: --end--

Research Question: Is there a relationship between life adverse events and breast cancer?

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