Rates, Ratios and Proportions

and Measures of Disease Frequency

 Introduction
• Public health questions are about populations

• Information about population characteristics is

often summarized in an index

• Changes in population characteristics can be

assessed by comparing summary measures
 Rates, Ratios, Proportions
• Three general classes of mathematical
parameters.

• Often used to relate the number of cases of a

disease or health outcome to the size of the
source population in which they occurred.
 Ratios, Rates, Proportion
• A ratio can be written as one number divided by another
(a fraction) of the form a/b Both a and b refer to the
frequency of some event or occurrence

• A proportion is a ratio in which the numerator is a

subset (or part) of the denominator and can be written as
a/(a+b) A relative frequency

• A rate is a ratio of the form a*/ (a+b) a* = the frequency

of events during a certain time period
a+b = the number at risk of the event during that time
period
 Ratio & Proportion

Female Female
All Male

Ratio

Proportion
 General Formula

The basic formula is as follows:

Numerator(x)
Measure =
Denominator(y)
 Ratio
• Obtained by dividing one quantity by another. These
quantities may be related or may be totally independent.

• Usually expressed as: x

10 n

y
Example: Number of stillbirths per thousand live births.

# stillbirth s
1000
# live births

• Numerator is not part of denominator

• General term that includes Rates and Proportions.
 Ratio

Example: A foodborne epidemic occurred in an elementary

school. The attack rate in the first grade was 24% while
the attack rate in the second grade was 16%. Compare
these two attack rates.

24% 1.5

16% 1

• Risk Ratio or Relative Risk

 Proportion
• A ratio in which the numerator is included in the
denominator.
x
• Expressed as: 10 n
where, 10n is often 100.
y
Example: The number of fetal deaths out of the total
number of births.
# of fetal deaths
100
live births  fetal deaths

• Expressed as a percent.
 Proportion
Example: 500 people attended a company
picnic and 50 became ill with acute enteric
disease. Calculate the proportion of ill
persons.
50
 100  10.0%
500
 Rate
• A measure of how quickly change of interest happens
over time.
x
• Expressed as: 10n
y
Example: The number of new cases of Parkinson’s
disease which develops per 1,000 person-years of
follow-up.
# of new cases of Parkinson' s disease
1000
Total time disease - free subjects observed
• Time, place and population must be specified for each
type of rate.
 Rate
The basic formula for a rate is as follows:

Number of cases or events occurring

during a given time period
Rate =
Population at Risk during the same
time period
 Use of Ratios, Proportions, and Rates
Condition Ratios Proportions Rates
Morbidity Risk Ratio Attributable Incidence rate
(Relative Risk) proportion Attack rate
(Disease) Odds Ratio Point Prevalence Secondary attack rate
Incidence desnity
Period Prevalence
Mortality Death-to-case ratio Proportionate Crude mortality rate
Maternal Mortality ratio mortality Cause-specific
(Death) Proportionate mortality Case-fatality rate mortality rate
rate Age-specific mortality
rate
Race-specific mortality
rate
Age adjusted mortality
rate
Natality Low birth weight Crude birth rate
ratio Crude fertility rate
(Birth) Crude rate of natural
increase
 Measures of Disease Frequency
• Incidence (I): Measures new cases of a disease
that develop over a period of time.

• Prevalence (P): Measures existing cases of a

disease at a particular point in time or over a
period of time.
 Prevalence vs. Incidence

• Prevalence can be viewed as describing a pool of

disease in a population.

• Incidence describes the input flow of new cases into the

pool.

• Fatality and recovery reflects the output flow from the

pool.
 Relationship between incidence
and prevalence

In a STEADY STATE (i.e. if incidence is not

changing, and the population is stable)

Prevalence rate = incidence rate times the

duration of disease (P =
I x D)
 Point Prevalence Rate

Proportion of individuals in a specified

population at risk who have the disease of
interest at a given point in time.
 Point Prevalence
C
P
N
C = # of observed cases at time t
N = Population size at time t

Measures the frequency of disease at a given

point in time
 Point Prevalence
Example
Suppose there are 150 individuals in a
population and, on a certain day, 15 are ill
with the flu. What is the estimated
prevalence for this population?

15
P  10%
150
 Period Prevalence
Proportion of individuals in a specified
population at risk who have the disease of
interest over a specified period of time.

For example:
• annual prevalence rate
• lifetime prevalence rate.
(When the type of prevalence rate is not specified it is
usually point prevalence, or its closest practical
approximation)
 Period Prevalence

CI
PP 
N
• C = the # of prevalent cases at the beginning of the time
period.

• I = the # of incident cases that develop during the period.

• N = size of the population for this same time period.

 Prevalence
Useful for:
• Assessing the health status of a population.
• Planning health services.

Not Useful for:

• Identifying risk factors
 Example
Suppose we followed a population of 150 persons for one
year, and 25 had a disease of interest at the start of
follow-up and another 15 new cases developed during
the year.

1) What is the period prevalence for the year?

2) What is the point prevalence at the start of the period?

3) What is the cumulative incidence for the one year

period?
 Example
Suppose we followed a population of 150 persons for one
year, and 25 had a disease of interest at the start of
follow-up and another 15 new cases developed during
the year.

1) What is the period prevalence for the year?

PP = (25 + 15) / 150 = 0.27 or 27%

2) What is the point prevalence at the start of the period?

P = 25/150 = 0.17 = 17%

3) What is the cumulative incidence for the one year

period?
CI = 15/125 = 0.12 = 12%
 Incidence

Like prevalence, divided into two types:

1. Cumulative incidence rate
2. Incidence density
1. Cumulative incidence rate:

Number of new cases of disease

occurring over a specified period
of time in a population at risk at the
beginning of the interval.
EXAMPLE OF CUMULATIVE
INCIDENCE RATE

If we count all new cases of influenza

occurring in ABU undergraduates from
September 1, 1997 - August 31, 1998,
and we take as the denominator all
undergraduates enrolled in September
1, 1997, we would be describing the
cumulative incidence rate of influenza.
 Cumulative Incidence
I
CI 
N
I = # of new cases during follow-up
N = # of disease-free subjects at start of follow-up

Measures the frequency of addition of new cases

of disease and is always calculated for a given
period of time.
Example
 Cumulative Incidence
• Most common way to estimate risk.
• Always a proportion
• Assumes a fixed cohort
• For brief specified periods of time, e.g. an
outbreak, commonly called an Attack “Rate”

- Beware of attrition
- Formula does not reflect continually changing
population size for dynamic cohorts.
- Does not allow subjects to be followed for
different time periods.
 2. Incidence density:

Number of new cases of disease

occurring over a specified period of time
in a population at risk throughout the
interval.
The numerator does not differ between the two types of
incidence
However, the denominator can differ in incidence density
from cumulative incidence because it takes account of
(in the example):

•Students who left school during the year

•Students who died
•Students who had influenza once and will not
have it again the same season
•Students who entered school later in the year
Incidence density requires us to add
up the period of time each individual
was present in the population, and
was at risk of becoming a new case
of disease.
Incidence density characteristically
uses as the denominator person-
years at risk. (Time period can be
person-months, days, or even hours,
depending on the disease process
being studied.)
The mortality rate is a type of
incidence rate which we will
discuss in more detail next
week. It is the most widely used
public health measure, but it has
limitations.
 Person-time Rate – Incidence
Density
The formula for person time rate is :

# cases during observation period

PtR = X 10 n
Time each person observed, Totaled for all
person
 Attack Rate
The formula for attack rate is :

# new cases of a specified diseases

reported during an epidemic period
AR =
Population at start of The epidemic period
 Secondary Attack Rate
The formula for secondary attack rate is :
# new cases of a specified
diseases among contacts of known cases
occurring within one incubation period

SAR =
Size of contact Population at risk
 Uses of incidence and prevalence
1. Incidence is generally used for acutely acquired
diseases, prevalence is used for more permanent
states, conditions or attributes of ill-health.
2. Incidence is more important when thinking of
etiology of the disorder, prevalence when thinking of
societal burden of the disorder including the costs
and resources consumed as a result of the disorder.

3. Incidence always requires a duration, prevalence

may or may not.
4. In incidence, the unit of analysis is the event, in
prevalence, it is the person. Thus incidence
may exceed 100% (e.g. annual incidence of
colds) unless a convention is adopted to count
only first episodes of an illness that can occur
more than once.
5. Prevalence can never exceed 100%.
6. Incidence generally requires an initial disease-
free interval before counting starts, because
incidence is measured only in those at-risk of
disease.
Uses of incidence density and
cumulative incidence

o Incidence density gives the best

estimate of the true risk of acquiring
disease at any moment in time.
o Cumulative incidence gives the best
estimate of how many people will
eventually get the disease in an
enumerated population.
 Risk (proportion)

0 ≤ RISK≤ 1

0% ≤ percentage ≤ 100%

Specify risk period

Example:
The 10-year risk that a 45-year-old male will
develop prostate cancer is 5%.
 Rate
• Describes how rapidly health events are occurring in a
population of interest.

• In Epidemiologic studies, we typically measure the

average rate at which a disease is occurring over a
period of time.

• Example:
50 new cases per 10,000 person-years

Interpretation:
An average of 50 cases occurs for every 10,000 years
of disease free follow-up time observed on a cohort of
subjects.
 Rate
Which of these describes a rate?

1) 5 new cases per 100 person days

2) 40 miles per hour
3) 10 new cases out of 100 disease-free persons
4) 60 new murders per year
5) 60 deaths out of 200 lung cancer patients
 Example
Hypothetical cohort of 12 initially disease-free subjects
followed over a 5-year period from 1990 to 1995.
 Example, cont.
 I 5
IR    0.20
PT 25PY

 20 new cases per 100 person - years

Study questions:
1) Is the value of 0.20 a proportion?
2) Does the value of 0.20 represent the risk of developing
disease?
 Study Questions
1) Is point prevalence a proportion?

2) Suppose 13 people from a population of size 406,245

had a particular disease at time t. What is the point
prevalence of this disease at time t?

3) Which of the following expressions is equivalent to the

point prevalence estimate of 0.000032?
a. 3.2 per 1,000
b. 3.2 per 100,000
c. 32 per 100,000
 Frequently Used Measures of Morbidity
Measure Numerator (x) Denominator (y) Expressed per
Number at Risk (10n)

Incidence Rate # new cases of a specified Average population Varies :

disease reported during a during time interval 10n where
given time interval n = 2,3,4,5,6
Attack Rate # new cases of a specified Population at start of varies
diseases reported during The epidemic period 10n where
an epidemic period n = 2,3,4,5,6

Secondary # new cases of a specified Size of contact varies

Attack Rate diseases among contacts of Population at risk 10n where
known cases n = 2,3,4,5,6
Point # current cases, new and Estimated population at varies
Prevalence old, of a specified the same point in 10n where
disease at a given point time n = 2,3,4,5,6
in time
Period # current cases, new and Estimated population at varies
Prevalence old, of a specified mid-interval 10n where
disease identified over a n = 2,3,4,5,6
given time interval
 References
• ActivEpi CD-ROM; Kleinbaum

• ActivEpi Companion Textbook; Kleinbaum,

Sullivan, Barker

• Epidemiology in Medicine, Hennekens