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Measures of Morbidity

James Maxwell, physicist (18311879)

We owe all the great advances in knowledge to those who endeavour to find out how much there is of anything. James Maxwell, physicist (18311879)

William Thomson, engineer, mathematician, and physicist (18241907)

If you can measure that of which you speak, and can express it by a number, you know something of your subject, but if you cannot measure it, your knowledge is meager and unsatisfactory. William Thomson, engineer, mathematician, and physicist (18241907)

Sources of data for illness

Measures of Morbidity
Incidence Prevalence

Incidence
Measured by incidence rate: the number of new cases of a disease that occur during a specified period of time in a population at risk for developing the disease.

Incidence rate
Cumulative Incidence Incidence density

Cumulative Incidence
(Number of new cases during a given period of time/Population at risk during the same time period) x 1000

Example
Among 60 people attending a 12-month residential detoxification program in Mysore, 50 tested HIV negative at the start of the program in January 1998. At the end of the program in December 1998, 3 of the 50 participants tested positive for HIV. Calculate the cumulative incidence.

Incidence Density
Number of new cases during a given period Total person-time of observation

Uses of Incidence rates


Measures the risk of acquiring the disease To identify the cause or etiology of disease To explore the relationship between an exposure and the risk of disease

Prevalence
number of affected persons present in the population at a specific time divided by the number of persons in the population at that time ??? what proportion of the population is affected by the disease at that time?

Prevalence
Measured by Prevalence Rate Divided into two types: 1. Point prevalence rate 2. Period prevalence rate

POINT PREVALENCE RATE


Proportion of individuals in a specified population at risk who have the disease of interest at a given point in time.

PERIOD PREVALENCE RATE


Proportion of individuals in a specified population at risk who have the disease of interest over a specified period of time. Annual prevalence rate
(When the type of prevalence rate is not specified it is usually point prevalence)

Relation between Incidence and Prevalence

When Insulin was introduced for the first time, what happened to the prevalence of diabetes?

Relation between Incidence and Prevalence

Prevalence = Incidence Duration of disease


P= I x D

City Mysore Mandya

Population screened 1000 1000

Positive CXR for TB 100 60

City Mysore Mandya

Population screened 1000 1000

Positive CXR Prevalence Incidence for TB 100 100 4 60 60 20

City

Prevalence Incidence Duration

Mysore Mandya

100 60

4 20

25 years 3 years

Uses of Prevalence rates


Measures -burden of disease in a community. Eg: How many people in the community have arthritis? To determine -how many clinics are needed -what types of rehabilitation services are needed -how many and what types of health professionals are needed. Needed for planning health services. To make future projections and To anticipate the changes

Exercises

Exercises-1
In 2005 all the children in Government schools of Nanjangud were examined for evidence of leprosy. The procedure was repeated again in 2006. The following were the results:

Exercise 1 contd
2005 a. No. of children on the rolls 52,600

b. No. of children examined c. No. of children found to have active leprosy 2006
d. e. f. g. h. i. No. of children on rolls No. of children examined for the first time No. of active cases among the above No. of children re-examined No. of old cases among them (i) Active (ii) Inactive No. of new cases among the re-examined

48,000 288
54,000 6,000 46 40,000 40 200 80

Exercise 1 contd
Questions: 1. 2. 3. What proportion of children on the rolls were examined? What was the prevalence of leprosy? a. in 2005 b. in 2006

a. in 2005 b. in 2006 What was the incidence of leprosy during 2005-2006?

4.

5.

Can the estimated prevalence and incidence rate be said to be applicable to: a. The entire group of school children b. All children in the area belonging to 5-14 yrs age group Had the second survey been conducted in 2007 (instead of 2006) and X no. of new cases been detected from N no. of re-examined children, what would be the formula for annual incidence rate?

Exercise 2
200 new born children were followed up till their 2nd birthday to study the incidence of diarrhoea. The following table shows the distribution of the children according to the number of diarrhoeal episodes.

No. of episodes 0 1 2 3 4 5 Total

Number of children 1st year 0 40 120 20 15 5 200 2nd year 40 80 60 15 3 2 200

Exercise 2 contd
Calculate the incidence of diarrhoea
a. During the first year b. During the second year c. Overall during the first 2 years of life.

Attack rate

Expressed as percentage

Specific attack rate


Food specific attack rate

Exercise
After a dinner attended by 100 people, 12 individuals become ill. All 100 people are interviewed about their food consumption at the dinner. The interviews show that 8 of the 12 people who are ill and 25 of the 88 who are healthy ate fish.

ILL Ate fish 8 Did not eat fish 4 12

WELL 25 63 88

Total 33 67 100

Attack rate

Eaten

Not eaten Not Ill 20 42 19 24 Total 29 60 30 49 Attack rate ILL 24 15 22 8 Not Ill 45 23 46 41 Total 69 38 68 49 Attack rate

ILL Breakfast Lunch Dinner Sandwich es 9 18 11 25

Eaten

Not eaten Not Ill 20 42 19 24 Total 29 60 30 49 Attack rate 31 30 37 51 ILL 24 15 22 8 Not Ill 45 23 46 41 Total 69 38 68 49 Attack rate 35 39 32 16

ILL Breakfast Lunch Dinner Sandwich es 9 18 11 25

Secondary Attack Rate (SAR)

Some definitions
Index Case
First Person who comes to the attention of public health authorities

Primary Case
First Person/s who acquires the disease from an exposure Attack rate

Secondary Case
Person who acquires the disease from an exposure to the primary case Secondary attack rate

Secondary Attack Rate (SAR)


Definition: No. of exposed (& susceptible) persons developing the disease within the range of the incubation period, following exposure to the primary case.

Secondary Attack Rate


Secondary attack rate (%)

No. of exposed persons developing the disease within the range of the incubation period Total no. of persons (susceptible &) exposed to the primary case

x 100

Used to estimate the spread of disease in a family, household, dorm or other group environment.

Measures the infectivity of the agent and the effects of prophylactic agents (e.g. vaccine)

Example:
Family of 6 consisting of 2 parents (already immune) and 4 children who are susceptible to measles. There occurs a primary case and within a short period of time 2 secondary cases among the remaining children. Calculate the SAR.

Mumps experience of 390 families exposed to a primary case within the family
Population
Age in years

Cases

Total
300 450 152

No. susceptible before Primary primary cases occurred

Secondary
50 87 15

2-4 5-9 10-19

250 420 84

100 204 25

Secondary attack rate 2-4 years old (50)/(250-100) x 100 = 33%

Exercise
Seven cases of hepatitis A occurred among 70 children attending a childcare center. Each infected child came from a different family. The total number of persons in the 7 affected families was 32. One incubation period later, 5 family members of the 7 infected children also developed hepatitis A. Calculate the attack rate in the child care center and the secondary attack rate among family contacts of those cases.

Attack rate in childcare center:

Cases of hepatitis A among children in childcare center Number of children enrolled in the childcare center

7
70

Secondary Attack rate among house hold contacts:


Cases of hepatitis A among family contacts of children with hepatitis A Number of persons at risk in the families

5
25

Age (yrs)

No. of persons exposed to a case

Cases of Hepatitis No. Secondary Attack rate (%)

Did not receive vaccine


0-4 5-9 10-14 15-19 20+ 0-4 5-9 10-14 15-19 20+ 42 45 32 26 83 Received vaccine 17 21 13 3 17 1 0 0 0 1 2 5 6 3 4

Age (yrs)

No. of persons exposed to a case

Cases of Hepatitis No. Secondary Attack rate (%)


4.8 11.1 18.8 11.5 4.8 6.0 0 0 0 1.4

Did not receive vaccine


0-4 5-9 10-14 15-19 20+ 0-4 5-9 10-14 15-19 20+ 42 45 32 26 83 Received vaccine 17 21 13 3 17 1 0 0 0 1 2 5 6 3 4

Herd Immunity

Herd Immunity
Resistance of a group of people to an attack by a disease to which a large proportion of the members of the group are immune.

Why does herd immunity occur?

Conditions to be met
The disease agent must be restricted to a single host species Transmission direct from one member of the host species to another Infections must induce solid immunity

Herd immunity operates if the probability of an infected person encountering every other individual in the population (random mixing) is the same.

What percentage of a population must be immune for herd immunity to operate?

Varies

Example
Poliomyelitis Two types of vaccines
OPV IPV

Why is the concept of herd immunity so important?