EPIDEMIOLOGY IN COMMUNITY HEALTH

TOPIC 1: INTRODUCTION TO IPIDEMIOLOGY

Epidemiology is the study of the distribution and determinants of health-related states or

events in specified populations, and the application of this study to the control of health
problems .Epidemiology is the study (scientific, systematic, data-driven) of the distribution
(frequency, pattern) and determinants (causes, risk factors) of health-related states and events
(not just diseases) in specified populations (patient is community, individuals viewed
collectively), and the application of (since epidemiology is a discipline within public health) this
study to the control of health problems.

Determinant: any factor, whether event, characteristic, or other definable entity, that brings about
a change in a health condition or other defined characteristic. Epidemiologists assume that illness
does not occur randomly in a population, but happens only when the right accumulation of risk
factors or determinants exists in an individual. To search for these determinants, epidemiologists
use analytic epidemiology or epidemiologic studies to provide the “Why” and “How” of such
events.

Specified populations

Although epidemiologists and direct health-care providers (clinicians) are both concerned with
occurrence and control of disease, they differ greatly in how they view “the patient.” The
clinician is concerned about the health of an individual; the epidemiologist is concerned about
the collective health of the people in a community or population. In other words, the clinician’s
“patient” is the individual; the epidemiologist’s “patient” is the community. Therefore, the
clinician and the epidemiologist have different responsibilities when faced with a person with
illness. For example, when a patient with diarrheal disease presents, both are interested in
establishing the correct diagnosis. However, while the clinician usually focuses on treating and
caring for the individual, the epidemiologist focuses on identifying the exposure or source that
caused the illness; the number of other persons who may have been similarly exposed; the
potential for further spread in the community; and interventions to prevent additional cases or

Epidemiological surveillance is “the ongoing systematic collection, analysis, and interpretation

of health data essential to the planning, implementation, and evaluation of public health practice,
closely integrated with the timely dissemination of these data to those who need to know.”
 Surveillance in general means to watch over carefully or to observe any event. For general
example use of CCTV is also a kind of a surveillance.
 Surveillance in public health is the continuous, watching of the incidence and distribution
of health-related events through systematic collection, analysis and interpretation of data
needed for the planning, implementation, and evaluation of public health practice.
 It can be carried out to monitor changes in disease frequency or to monitor changes in the
levels of risk factors.
 Surveillance is systematic and ongoing process
 USES OF EPIDEMIOLOGY

Surveillance
Systematic ongoing collection, collation, and analysis of data and the timely dissemination of
information to those who need to know so that action can be taken. The ongoing systematic
collection, analysis, and interpretation of health data, essential to the planning, implementation,
and evaluation of public health practice, closely integrated with the timely dissemination of these
data to those who need to know. Surveillance is the continuous gathering of health data needed
to monitor the population's health status in order to provide or revise needed services.
Note the words "dissemination...to those who need to know" in both definitions. This means that
collection of health data without sharing and using those data is NOT surveillance.

Public Health Surveillance

Purpose and Characteristics of Public Health Surveillance

1.Public health surveillance provides and interprets data to facilitate the prevention and control
of disease. To achieve this purpose, surveillance for a disease or other health problem should
have clear objectives. These objectives should include a clear description of how data that are
collected, consolidated, and analyzed for surveillance will be used to prevent or control the
disease. For example, the objective of surveillance for tuberculosis might be to identify persons
with active disease to ensure that their disease is adequately treated. For such an objective, data
collection should be sufficiently frequent, timely, and complete to allow effective treatment.
Alternatively, the objective might be to determine whether control measures for tuberculosis are
effective. To meet this objective, one might track the temporal trend of tuberculosis, and data
might not need to be collected as quickly or as frequently. Surveillance for a health problem can
have more than one objective.

Critical characteristics of surveillance

 Timeliness, to implement effective control measures;

 Representation, to provide an accurate picture of the temporal trend of the disease;
 Sensitivity, to allow identification of individual persons with disease to facilitate treatment;
quarantine, or other appropriate control measures; and
 Specificity, to exclude persons not having disease.
To establish the objectives of surveillance for a particular disease in a specific setting and to
select an appropriate method of conducting surveillance for that disease, asking and answering
the following questions will be helpful.

 What is the health-related event under surveillance? What is its case definition?
 What is the purpose and what are the objectives of surveillance?
 What are the planned uses of the surveillance data?
 What is the legal authority for any data collection?
 Where is the organizational home of the surveillance?
 Is the system integrated with other surveillance and health information systems?
 What is the population under surveillance?
 What is the frequency of data collection (weekly, monthly, annually)?
 What data are collected and how? Would a sentinel approach or sampling be more
effective?
 What are the data sources? What approach is used to obtain data?
 During what period should surveillance be conducted? Does it need to be continuous, or
can it be intermittent or short-term?
 How are the data processed and managed? How are they routed, transferred, stored? Does
the system comply with applicable standards for data formats and coding schemes? How
is confidentiality maintained?
 How are the data analyzed? By whom? How often? How thoroughly?
 How is the information disseminated? How often are reports distributed? To whom? Does
it get to all those who need to know, including the medical and public health communities
and policymakers?

Concepts of Disease Occurrence
A critical premise of epidemiology is that disease and other health events do not occur
randomly in a population, but are more likely to occur in some members of the population
than others because of risk factors that may not be distributed randomly in the population. As
noted earlier, one important use of epidemiology is to identify the factors that place some
members at greater risk than others.
Causation
A number of models of disease causation have been proposed. Among the simplest of these
is the epidemiologic triad or triangle, the traditional model for infectious disease. The triad
consists of an external agent, a susceptible host, and an environment that brings the host and
agent together. In this model, disease results from the interaction between the agent and the
susceptible host in an environment that supports transmission of the agent from a source to
that host. Two ways of depicting this model are shown in Figure 1.16.
Agent, host, and environmental factors interrelate in a variety of complex ways to produce
disease. Different diseases require different balances and interactions of these three
components. Development of appropriate, practical, and effective public health measures to
control or prevent disease usually requires assessment of all three components and their
interactions.
Agent originally referred to an infectious microorganism or pathogen: a virus, bacterium,
parasite, or other microbe. Generally, the agent must be present for disease to occur;
however, presence of that agent alone is not always sufficient to cause disease. A variety of
factors influence whether exposure to an organism will result in disease, including the
organism’s pathogenicity (ability to cause disease) and dose.
Over time, the concept of agent has been broadened to include chemical and physical causes
of disease or injury. These include chemical contaminants (such as the L-tryptophan
contaminant responsible for eosinophilia-myalgia syndrome), as well as physical forces (such
as repetitive mechanical forces associated with carpal tunnel syndrome). While the
epidemiologic triad serves as a useful model for many diseases, it has proven inadequate for
cardiovascular disease, cancer, and other diseases that appear to have multiple contributing
causes without a single necessary one.
Host refers to the human who can get the disease. A variety of factors intrinsic to the host,
sometimes called risk factors, can influence an individual’s exposure, susceptibility, or
response to a causative agent. Opportunities for exposure are often influenced by behaviors
such as sexual practices, hygiene, and other personal choices as well as by age and sex.
Susceptibility and response to an agent are influenced by factors such as genetic composition,
nutritional and immunologic status, anatomic structure, presence of disease or medications,
and psychological makeup.
Environment refers to extrinsic factors that affect the agent and the opportunity for
exposure. Environmental factors include physical factors such as geology and climate,
biologic factors such as insects that transmit the agent, and socioeconomic factors such as
crowding, sanitation, and the availability of health services.
Epidemic Disease Occurrence
Level of disease
The amount of a particular disease that is usually present in a community is referred to as the
baseline or endemic level of the disease. This level is not necessarily the desired level, which
may in fact be zero, but rather is the observed level. In the absence of intervention and
assuming that the level is not high enough to deplete the pool of susceptible persons, the
disease may continue to occur at this level indefinitely. Thus, the baseline level is often
regarded as the expected level of the disease.
While some diseases are so rare in a given population that a single case warrants an
epidemiologic investigation (e.g., rabies, plague, polio), other diseases occur more commonly
so that only deviations from the norm warrant investigation. Sporadic refers to a disease that
 occurs infrequently and irregularly. Endemic refers to the constant presence and/or usual
prevalence of a disease or infectious agent in a population within a geographic area.
Hyperendemic refers to persistent, high levels of disease occurrence.
Occasionally, the amount of disease in a community rises above the expected level. Epidemic
refers to an increase, often sudden, in the number of cases of a disease above what is
normally expected in that population in that area. Outbreak carries the same definition of
epidemic, but is often used for a more limited geographic area. Cluster refers to an
aggregation of cases grouped in place and time that are suspected to be greater than the
number expected, even though the expected number may not be known. Pandemic refers to
an epidemic that has spread over several countries or continents, usually affecting a large
number of people.
Epidemics occur when an agent and susceptible hosts are present in adequate numbers, and
the agent can be effectively conveyed from a source to the susceptible hosts. More
specifically, an epidemic may result from:
• A recent increase in amount or virulence of the agent,
• The recent introduction of the agent into a setting where it has not been before,
• An enhanced mode of transmission so that more susceptible persons are exposed,
• A change in the susceptibility of the host response to the agent, and/or
• Factors that increase host exposure or involve introduction through new portals of entry.
(4
Selecting a Health Problem for Surveillance
Because conducting surveillance for a health problem consumes time and resources, taking care
in selecting health problems for surveillance is critical. In certain countries, selection is based on
criteria developed for prioritizing diseases, review of available morbidity and mortality data,
knowledge of diseases and their geographic and temporal patterns, and impressions of public and
political concerns, sometimes augmented with surveys of the general public or no health-
associated government officials. Criteria developed for selecting and prioritizing health problems
for surveillance include the following:

Public health importance of the problem:

 incidence, prevalence,
 severity, sequela, disabilities,
 mortality caused by the problem,
 socioeconomic impact,
 communicability,
 potential for an outbreak,
 public perception and concern, and
 international requirements.
Ability to prevent, control, or treat the health problem:
 preventability and
 control measures and treatment.
Capacity of health system to implement control measures for the health problem:
 speed of response,
  economics,
 availability of resources, and
 what surveillance of this event requires?

Characteristics of Ideal Surveillance:

An ideal surveillance should be:

 Simple
 Timely
 Representative
 Flexible
 Sensitive
 Strong predictive value
 Acceptable to
 The public
 Health care providers
 Cost-effective

Importance of surveillance:

 To assess the health status

 All the data collected are the reflection of health of people
 Keeps the record of existing health problems
 Helps in the interpretation of mortality and morbidity status
 To detect the change in the disease trend and health practices
 Continue recording of data notifies about the disease trend
 Keeps the track of disease
 Surveillance is also helpful for finding the natural history of disease.
 Collection of data for Planning, Monitoring and Evaluation
 The data required for PME is provided by surveillance
 It is the base for evidence-based policy formation
 Helps the program developer in priority setting
 Also helps in assessing the effectiveness of the interventions
 Early warning and detection of outbreaks
 Surveillance notifies about the disease
 All the data too helps in detecting the outbreaks
 Hence helps in preparedness
 To estimate the size of a health problem
 To detect epidemics or define a problem
  To facilitate emergency planning
 Surveillance data can also be used to test hypotheses

Types of Surveillance:

1. Active Surveillance

 Refers to active finding of the cases.

 Designated staffs review the records physically, visits the health facility, and confirms
with the health practitioner to find the particular cases.
 Often used for the disease which is at the verge of elimination and eradication and also in
the time of outbreak investigation.
 Requires more resources
 Active Surveillance can be also used to check the validity of passive surveillance
 Reporting is usually more accurate here as it is performed by those specially assigned to
conduct this activity

2. Passive Surveillance

 Surveillance in which the available data on diseases or conditions are used

 It refers to regular monitoring or reporting of the cases without active involvement in
identification/reporting by the health personnel
 Simple and very easy to carry out
 All institutions that provide health services to general people are the part of this
surveillance.
 They forward their records to the designated departments where all the reports are
compiled
 Uniform format of reporting is followed
 Health management information system of government is an example of passive
surveillance
 Inconsistency of recording can cause problem as things may not be taken seriously all the
time

3. Sentinel Surveillance

 It is a surveillance system which is used when the need of high quality data cannot be met
through passive surveillance
 It is a system where specific catchment area is selected for surveillance.
 Selection of sentinel surveillance site depends on possibility of high probability of
cases/disease
 It deliberately involves limited network of carefully selected reporting sites. Example: a
network of large hospitals might be used to collect high-quality data on various diseases
  Sites are selected on the basis of population flow, previous outbreak of disease, high
presence of risk group, etc.
 Sentinel Surveillance is not suitable for detecting rare disease

Steps of surveillance:

Reporting:

 Data has to be reported by the health worker, staffs , etc

 Data needs to be reported in pre-specified format

Accumulation

 The reported data needs to be collected and compiled

 The data are collected in a designated departments
 Data collection follows the certain chain

Data Analysis

 All the collected are then analyzed

 The data are converted in terms of rates, ratios, proportion, figures etc

Interpretation and action

 Surveillance doesn’t stops in data collection

 Wise judgement needs to be made
 The information needs to be disseminated so that the further action are taken

Identifying or Collecting Data for Surveillance

After the problem for surveillance has been identified and defined and the needs and scope
determined, available reports and other relevant data should be located that can be used to
conduct surveillance. These reports and data are gathered for different purposes from multiple
sources by using selected methods. Data might be collected initially to serve health-related
purposes, whereas data might later serve administrative, legal, political, or economic purposes.
Examples of the former include collecting data from death certificates regarding the cause and
circumstances of death and collecting data from national health surveys regarding health-related
behaviors; examples of the latter include collecting data on cigarette and alcohol sales and
administrative data generated from the reimbursement of health-care providers.

Before describing available local and national data resources for surveillance, understanding the
principal sources and methods of obtaining data about health problems is helpful. As you recall
from Lesson 1, the majority of diseases have a characteristic natural history. An understanding of
the natural history of a disease is critical to conducting surveillance for that disease because
someone — either the patient or a health-care provider — must recognize, or diagnose, the
disease and create a record of its existence for it to be identified and counted for surveillance. For
diseases that cause severe illness or death (e.g., lung cancer or rabies), the likelihood that the
disease will be diagnosed and recorded by a health-care provider is high. For diseases that
produce limited or no symptoms in the majority of those affected, the likelihood that the disease
will be recognized is low. Certain diseases fall between these extremes. The characteristics and
natural history of a disease determine how best to conduct surveillance for that disease.

Sources and Methods for Gathering Data

Data collected for health-related purposes typically come from three sources, individual persons,
the environment, and health-care providers and facilities.

Individual persons
Health-care providers, facilities, and records
 Physician offices
 Hospitals
 Outpatient departments
 Emergency departments
 Inpatient settings
 Laboratories
Environmental conditions
 Air
 Water
 Animal vectors
Administrative actions
Financial transactions
 Sales of goods and services
 Taxation
Legal actions
Laws and regulations
A limited number of methods are used to collect the majority of health-related data, including
environmental monitoring, surveys, notifications, and registries. These methods can be further
characterized by the approach used to obtain information from the sources described previously.
For example, the method of collecting information might be an annual population survey that
uses an in-person interview and a standardized questionnaire for obtaining data from women
aged 18–45 years; or the method might be a notification that requires completion and submission
of a form by health-care providers about occurrences of specific diseases that they see in their
practices.

METHODS USED TO COLLECT SURVEILLANCE DATA

a) Environmental Monitoring
Examples of environmental monitoring
 Cities and states monitor air pollutants.
 Cities and towns monitor public water supplies for bacterial and chemical contaminants.
 State and local health authorities monitor beaches, lakes, and swimming pools for increased
levels of harmful bacteria and other biologic and chemical hazards.
 Health agencies monitor animal and insect vectors for the presence of viruses and parasites
that are harmful to humans.
 National, state, and local departments of transportation monitor roads, highways, and
bridges to ensure that they are safe for traffic; they also monitor traffic to ensure that speed
limits and other traffic laws are observed.
 Public safety and health departments periodically monitor compliance with laws requiring
seat belt use.
 Occupational health authorities monitor noise levels in the workplace to prevent hearing
loss among employees.
Monitoring the environment is critical for ensuring that it is healthy and safe (see Examples of
Environmental Monitoring). Multiple qualitative and quantitative approaches are used to monitor
the environment, depending on the problem, setting, and planned use of the monitoring data.

b) Survey

A survey is an investigation that uses a “structured and systematic gathering of information”

from a sample of “a population of interest to describe the population in quantitative term The
majority of surveys gather information from a representative sample of a population so that the
results of the survey can be generalized to the entire population. Surveys are probably the most
common method used for gathering information about populations. The subjects of a survey can
be members of the general public, patients, health-care providers, or organizations. Although
their topics might vary widely, surveys are typically designed to obtain specific information
about a population and can be conducted once or on a periodic basis.

c) Notification

A notification is the reporting of certain diseases or other health-related conditions by a specific

group, as specified by law, regulation, or agreement. Notifications are typically made to the state
or local health agency. Notifications are often used for surveillance, and they aid in the timely
control of specific health problems or hazardous conditions. When reporting is required by law,
the diseases or conditions to be reported are known as notifiable diseases or conditions.

Individual notifiable disease case reports are considered confidential and are not available for
public inspection. In most states, a case report from a physician or hospital is sent to the local
health department, which has primary responsibility for taking appropriate action. The local
health department then forwards a copy of the case report to the state health department. In states
that have no local health departments or in which the state heath department has primary
responsibility for collecting and investigating case reports, initial case reports go directly to the
state health department. In some states all laboratory reports are sent to the state health
department, which informs the local health department responsible for following up with the
physician.
This form of data collection, in which health-care providers send reports to a health department
on the basis of a known set of rules and regulations, is called passive surveillance (provider-
initiated). Less commonly, health department staff may contact healthcare providers to solicit
reports. This active surveillance (health department-initiated) is usually limited to specific
diseases over a limited period of time, such as after a community exposure or during an outbreak

Types of Notification and Examples

1. Disease or hazard-specific notifications

1. Communicable diseases
1. World Health Organization: International health regulations require
reporting of cholera, plague, and yellow fever
2. National: United States and Canada specify diseases that require notification
by all states and provinces, respectively
3. Provincial, state, or subnational: for example, coccidioidomycosis in
California
2. Chemical and physical hazards in the environment
1. Childhood lead poisoning
2. Occupational hazards
3. Firearm-related injury
4. Consumer product-related injury
2. Notifications related to treatment administration
1. Adverse effect of drugs or medical products
2. Adverse effect from vaccines
3. Notifications related to persons at risk
1. Elevated blood lead among adults
2. Elevated blood lead among children

d) Registries

Maintaining registries is a method for documenting or tracking events or persons over time
(Table 5.4). Certain registries are required by law (e.g., registries of vital events). Although
similar to notifications, registries are more specific because they are intended to be a permanent
record of persons or events. For example, birth and death certificates are permanent legal records
that also contain important health-related information. A disease registry (e.g., a cancer registry)
tracks a person with disease over time and usually includes diagnostic, treatment, and outcome
information. Although the majority of disease registries require health facilities to report
information on patients with disease, an active component might exist in which the registry
periodically updates patient information through review of health, vital, or other records.

e) Reanalysis or Secondary Use of Data

Surveillance for a health problem can use data originally collected for other purposes — a
practice known as the reanalysis or secondary use of data. This approach is efficient but can
suffer from a lack of timeliness, or it can lack sufficient detail to address the problem under
surveillance. Because the primary collection of data for surveillance is time-consuming and
resource-intensive if done well, it should be undertaken only if the health problem is of high
priority and no other adequate source of data exists.

Types of Registries and Examples of Selected Types

1. Vital event registration

1. Birth registration
2. Marriage and divorce registration
3. Death registration
2. Registries used in preventive medicine
1. Immunization registries
2. Registries of persons at risk for selected conditions
3. Registries of persons positive for genetic conditions
3. Disease-specific registries
1. Blind registries
2. Birth defects registries
3. Cancer registries
4. Psychiatric case registries
5. Ischemic heart disease registries
4. Treatment registries
1. Radiotherapy registries
2. Follow-up registries for detection of iatrogenic thyroid disease
5. After-treatment registries
1. Handicapped children
2. Disabled persons
6. Registries of persons at risk or exposed
1. Children at high risk for developing a health problem
2. Occupational hazards registries
3. Medical hazards registries
4. Older persons or chronically ill registries
5. Atomic bomb survivors (Japan)
6. World Trade Center survivors (New York City)
7. Skills and resources registries
8. Prospective research studies
9. Specific information registries

Identifying or Collecting Data for Surveillance

After the problem for surveillance has been identified and defined and the needs and scope
determined, available reports and other relevant data should be located that can be used to
conduct surveillance. These reports and data are gathered for different purposes from multiple
sources by using selected methods. Data might be collected initially to serve health-related
purposes, whereas data might later serve administrative, legal, political, or economic purposes.
Examples of the former include collecting data from death certificates regarding the cause and
circumstances of death and collecting data from national health surveys regarding health-related
behaviors; examples of the latter include collecting data on cigarette and alcohol sales and
administrative data generated from the reimbursement of health-care providers.

Before describing available local and national data resources for surveillance, understanding the
principal sources and methods of obtaining data about health problems is helpful. As you recall
from Lesson 1, the majority of diseases have a characteristic natural history. An understanding of
the natural history of a disease is critical to conducting surveillance for that disease because
someone — either the patient or a health-care provider — must recognize, or diagnose, the
disease and create a record of its existence for it to be identified and counted for surveillance. For
diseases that cause severe illness or death (e.g., lung cancer or rabies), the likelihood that the
disease will be diagnosed and recorded by a health-care provider is high. For diseases that
produce limited or no symptoms in the majority of those affected, the likelihood that the disease
will be recognized is low. Certain diseases fall between these extremes. The characteristics and
natural history of a disease determine how best to conduct surveillance for that disease.

Examples of documentation of financial, legal, and administrative activities that might be used
for surveillance

 Receipts for cigarette and other tobacco product sales.

 Automated reports of pharmaceutical sales.
 Electronic records of billing and payment for health-care services.
 Laws and regulations related to drug use.

Sources and Methods for Gathering Data

Data collected for health-related purposes typically come from three sources, individual persons,
the environment, and health-care providers and facilities. Moreover, data collected for
nonhealth–related purposes (e.g., taxes, sales, or administrative data) might also be used for
surveillance of health-related problems. Because a researcher might wish to calculate rates of
disease, information about the size of the population under surveillance and its geographic
distribution are also helpful. Table 5.2 summarizes health and nonhealth-related sources of data,
and the box to the left provides examples of nonhealth-related data that can be used for
surveillance of specific health problems.

Table 5.2 Typical Sources of Data

Individual persons

Health-care providers, facilities, and records

 Physician offices
  Hospitals
 Outpatient departments
 Emergency departments
 Inpatient settings
 Laboratories

Environmental conditions

 Air
 Water
 Animal vectors

Administrative actions

Financial transactions

 Sales of goods and services

 Taxation

Legal actions

Laws and regulations

A limited number of methods are used to collect the majority of health-related data, including
environmental monitoring, surveys, notifications, and registries. These methods can be further
characterized by the approach used to obtain information from the sources described previously.
For example, the method of collecting information might be an annual population survey that
uses an in-person interview and a standardized questionnaire for obtaining data from women
aged 18–45 years; or the method might be a notification that requires completion and submission
of a form by health-care providers about occurrences of specific diseases that they see in their
practices.

Depending on the situation, these methods might be used to obtain information about a sample of
a population or events or about all members of the population or all occurrences of a specific
event (e.g., birth or death). Information might be collected continuously, periodically, or for a
defined period, depending on the need. Careful consideration of the objectives of surveillance for
a particular disease and a thorough understanding of the advantages and disadvantages of
different sources and methods for gathering data are critical in deciding what data are needed for
surveillance and the most appropriate sources and methods for obtaining it.(9, 14) We now
discuss each of these four methods.

Environmental Monitoring

Examples of environmental monitoring

 Cities and states monitor air pollutants.
 Cities and towns monitor public water supplies for bacterial and chemical contaminants.
  State and local health authorities monitor beaches, lakes, and swimming pools for increased
levels of harmful bacteria and other biologic and chemical hazards.
 Health agencies monitor animal and insect vectors for the presence of viruses and parasites that
are harmful to humans.
 National, state, and local departments of transportation monitor roads, highways, and bridges
to ensure that they are safe for traffic; they also monitor traffic to ensure that speed limits and
other traffic laws are observed.
 Public safety and health departments periodically monitor compliance with laws requiring seat
belt use.
 Occupational health authorities monitor noise levels in the workplace to prevent hearing loss
among employees.

Monitoring the environment is critical for ensuring that it is healthy and safe (see Examples of
Environmental Monitoring). Multiple qualitative and quantitative approaches are used to monitor
the environment, depending on the problem, setting, and planned use of the monitoring data.

Survey

A survey is an investigation that uses a “structured and systematic gathering of information”

from a sample of “a population of interest to describe the population in quantitative terms.”(15)
The majority of surveys gather information from a representative sample of a population so that
the results of the survey can be generalized to the entire population. Surveys are probably the
most common method used for gathering information about populations. The subjects of a
survey can be members of the general public, patients, health-care providers, or organizations.
Although their topics might vary widely, surveys are typically designed to obtain specific
information about a population and can be conducted once or on a periodic basis.

Notification

A notification is the reporting of certain diseases or other health-related conditions by a specific

group, as specified by law, regulation, or agreement. Notifications are typically made to the state
or local health agency. Notifications are often used for surveillance, and they aid in the timely
control of specific health problems or hazardous conditions. When reporting is required by law,
the diseases or conditions to be reported are known as notifiable diseases or conditions.

Individual notifiable disease case reports are considered confidential and are not available for
public inspection. In most states, a case report from a physician or hospital is sent to the local
health department, which has primary responsibility for taking appropriate action. The local
health department then forwards a copy of the case report to the state health department. In states
that have no local health departments or in which the state heath department has primary
responsibility for collecting and investigating case reports, initial case reports go directly to the
state health department. In some states all laboratory reports are sent to the state health
department, which informs the local health department responsible for following up with the
physician.

This form of data collection, in which health-care providers send reports to a health department
on the basis of a known set of rules and regulations, is called passive surveillance (provider-
initiated). Less commonly, health department staff may contact healthcare providers to solicit
reports. This active surveillance (health department-initiated) is usually limited to specific
diseases over a limited period of time, such as after a community exposure or during an outbreak.

Table 5.3 shows the types of notification and examples.

Table 5.3 Types of Notification and Examples

1. Disease or hazard-specific notifications

1. Communicable diseases
1. World Health Organization: International health regulations require reporting of
cholera, plague, and yellow fever
2. National: United States and Canada specify diseases that require notification by
all states and provinces, respectively
3. Provincial, state, or subnational: for example, coccidioidomycosis in California
2. Chemical and physical hazards in the environment
1. Childhood lead poisoning
2. Occupational hazards
3. Firearm-related injury
4. Consumer product-related injury
2. Notifications related to treatment administration
1. Adverse effect of drugs or medical products
2. Adverse effect from vaccines
3. Notifications related to persons at risk
1. Elevated blood lead among adults
2. Elevated blood lead among children

Adapted from: Koo D, Wingo P, Rothwell C. Health Statistics from Notifications, Registration Systems,
and Registries. In: Friedman D, Parrish RG, Hunter E (editors). Health Statistics: Shaping Policy and
Practice to Improve the Population’s Health. New York: Oxford University Press; 2005, p. 82.

Use of sentinel sites has become the preferred approach for human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS) surveillance for certain countries
where national population-based surveillance for HIV infection is not feasible. This approach is
based on periodic serologic surveys conducted at selected sites with well-defined population
subgroups (e.g., prenatal clinics). Under this strategy, health officials define the population
subgroups and the regions to study and then identify health-care facilities serving those
populations that are capable and willing to participate. These facilities then conduct serologic
surveys at least annually to provide statistically valid estimates of HIV prevalence.

Because underreporting is common for certain diseases, an alternative to traditional reporting is

sentinel reporting, which relies on a prearranged sample of health-care providers who agree to
report all cases of certain conditions. These sentinel providers are clinics, hospitals, or physicians
who are likely to observe cases of the condition of interest. The network of physicians reporting
influenza-like illness, as described in one of the examples in Appendix C, is an example of
surveillance that uses sentinel providers. Although the sample used in sentinel surveillance might
not be representative of the entire population, reporting is probably consistent over time because
the sample is stable and the participants are committed to providing high-quality data.

Registries

Maintaining registries is a method for documenting or tracking events or persons over time
(Table 5.4). Certain registries are required by law (e.g., registries of vital events). Although
similar to notifications, registries are more specific because they are intended to be a permanent
record of persons or events. For example, birth and death certificates are permanent legal records
that also contain important health-related information. A disease registry (e.g., a cancer registry)
tracks a person with disease over time and usually includes diagnostic, treatment, and outcome
information. Although the majority of disease registries require health facilities to report
information on patients with disease, an active component might exist in which the registry
periodically updates patient information through review of health, vital, or other records.

Reanalysis or Secondary Use of Data

Surveillance for a health problem can use data originally collected for other purposes — a
practice known as the reanalysis or secondary use of data. This approach is efficient but can
suffer from a lack of timeliness, or it can lack sufficient detail to address the problem under
surveillance. Because the primary collection of data for surveillance is time-consuming and
resource-intensive if done well, it should be undertaken only if the health problem is of high
priority and no other adequate source of data exists.

Table 5.4 Types of Registries and Examples of Selected Types

1. Vital event registration

1. Birth registration
2. Marriage and divorce registration
3. Death registration
2. Registries used in preventive medicine
1. Immunization registries
2. Registries of persons at risk for selected conditions
3. Registries of persons positive for genetic conditions
3. Disease-specific registries
1. Blind registries
2. Birth defects registries
3. Cancer registries
4. Psychiatric case registries
5. Ischemic heart disease registries
4. Treatment registries
1. Radiotherapy registries
2. Follow-up registries for detection of iatrogenic thyroid disease
5. After-treatment registries
1. Handicapped children
2. Disabled persons
6. Registries of persons at risk or exposed
 1. Children at high risk for developing a health problem
2. Occupational hazards registries
3. Medical hazards registries
4. Older persons or chronically ill registries
5. Atomic bomb survivors (Japan)
6. World Trade Center survivors (New York City)
7. Skills and resources registries
8. Prospective research studies
9. Specific information registries

Analyzing and Interpreting Data

After morbidity, mortality, and other relevant data about a health problem have been gathered
and compiled, the data should be analyzed by time, place, and person. Different types of data are
used for surveillance, and different types of analyses might be needed for each. For example,
data on individual cases of disease are analyzed differently than data aggregated from multiple
records; data received as text must be sorted, categorized, and coded for statistical analysis; and
data from surveys might need to be weighted to produce valid estimates for sampled populations.

For analysis of the majority of surveillance data, descriptive methods are usually appropriate.
The display of frequencies (counts) or rates of the health problem in simple tables and graphs, as
discussed in Lesson 5, is the most common method of analyzing data for surveillance. Rates are
useful — and frequently preferred — for comparing occurrence of disease for different
geographic areas or periods because they take into account the size of the population from which
the cases arose. One critical step before calculating a rate is constructing a denominator from
appropriate population data. For state- or countywide rates, general population data are used.
These data are available from the U.S. Census Bureau or from a state planning agency. For other
calculations, the population at risk can dictate an alternative denominator. For example, an infant
mortality rate uses the number of live-born infants; rates of surgical wound infections in a
hospital requires the number of such procedures performed. In addition to calculating
frequencies and rates, more sophisticated methods (e.g., space-time cluster analysis, time series
analysis, or computer mapping) can be applied.

Analyzing by time

Basic analysis of surveillance data by time is usually conducted to characterize trends and detect
changes in disease incidence. For notifiable diseases, the first analysis is usually a comparison of
the number of case reports received for the current week with the number received in the
preceding weeks. An abrupt increase or a gradual buildup in the number of cases can be detected
by looking at the table or graph. For example, health officials reviewing the data for Clark
County in. This method works well when new cases are reported promptly.

Another common analysis is a comparison of the number of cases during the current period to
the number reported during the same period for the last 2–10 years
Analysis of long-term time trends, also known as secular trends, usually involves graphing
occurrence of disease by year

Analyzing by place

The analysis of cases by place is usually displayed in a table or a map. State and local health
departments usually analyze surveillance data by neighborhood or by county. CDC routinely
analyzes surveillance data by state. Rates are often calculated by adjusting for differences in the
size of the population of different counties, states, or other geographic areas.

Analyzing by person

The most commonly collected and analyzed person characteristics are age and sex. Data
regarding race and ethnicity are less consistently available for analysis. Other characteristics
(e.g., school or workplace, recent hospitalization, and the presence of such risk factors for
specific diseases as recent travel or history of cigarette smoking) might also be available and
useful for analysis, depending on the health problem.

Age

Meaningful age categories for analysis depend on the disease of interest. Categories should be
mutually exclusive and all-inclusive. Mutually exclusive means the end of one category cannot
overlap with the beginning of the next category (e.g., 1–4 years and 5–9 years rather than 1–5
and 5–9). All-inclusive means that the categories should include all possibilities, including the
extremes of age (e.g., <1 year and ≥84 years) and unknowns.

The characteristic age distribution of a disease should be used in deciding the age categories —
multiple narrow categories for the peak ages, broader categories for the remainder. If the age
distribution changes over time or differs geographically, the categories can be modified to
accommodate those differences.

Interpreting results of analyses

When the incidence of a disease increases or its pattern among a specific population at a
particular time and place varies from its expected pattern, further investigation or increased
emphasis on prevention or control measures is usually indicated. The amount of increase or
variation required for action is usually determined locally and reflects the priorities assigned to
different diseases, the local health department’s capabilities and resources, and sometimes,
public, political, or media attention or pressure.

Development of the Concept of Surveillance

Disease surveillance" as the collection, analysis, and dissemination of data on specific diseases
Planning a surveillance system begins with a clear understanding of the purpose of surveillance
in the context of public health, surveillance may be established to meet a variety of objectives,
including assessment of public health status, establishment of public health priorities, evaluation
of programs, and conduct of research.
Steps in planning a surveillance system

1. Establish objectives
2. Develop case definitions
3. Determine data sources data-collection mechanism
(type of system)
4. Determine data-collection instruments
5. Field-test methods
6. Develop and test analytic approach
7. Develop dissemination mechanism
8. Assure use of analysis and interpretation

Section 7: Evaluating and Improving Surveillance

Surveillance for a disease or other health-related problem should be evaluated periodically to

ensure that it is serving a useful public health function and is meeting its objectives. Such an
evaluation: (1) identifies elements of surveillance that should be enhanced to improve its
attributes, (2) assesses how surveillance findings affect control efforts, and (3) improves the
quality of data and

Flow chart of Kenya surveillance system

 Limitations

Underreporting. For the majority of notifiable diseases, data for surveillance are based on
passive reporting by physicians and other health-care providers. Studies have demonstrated that
in the majority of jurisdictions, only a fraction of cases of the notifiable diseases overall are ever
reported.The most obvious result of such underreporting is that effective action is delayed, and
cases occur that might have been prevented by prompt reporting and prompt initiation of control
measures. For example, if a case of hepatitis A in a food handler goes unreported, the
opportunity to provide protective immune globulin to restaurant patrons will be missed, and
cases or an outbreak of hepatitis A that should have been prevented will instead occur. However,
underreported data might still be useful for assessing trends or other patterns reflecting the
occurrence or burden of disease.

Health-care providers cite a number of reasons for not reporting.Selected reasons are listed in the
following text. Public health agencies must recognize these barriers to reporting, because the
majority are within an agency’s power to address or correct.

Lack of knowledge of reporting requirements:

 Lack of awareness of responsibility to report.
 Lack of awareness of which diseases must be reported.
 Lack of awareness of how or to whom to report.
 Assumption that someone else (e.g., the laboratory) will report.
Negative attitude toward reporting:
 Time consuming.
 Hassle (e.g., a lengthy or complex report form or procedure).
 Lack of incentive.
 Lack of feedback.
 Distrust of government.
Misconceptions that result from lack of knowledge or negative attitude:
 Compromises patient-physician relationship.
 Concern that report might result in a breach of confidentiality (e.g., HIPAA concerns).
 Disagreement with need to report.
 Judgment that the disease is not that serious.
 Belief that no effective public health measures exist.
 Perception that health department does not act on the reports.
Lack of representativeness of reported cases. Underreporting is not uniform or random. Two
important biases distort the completeness of reporting. First, health-care providers are more
likely to report a case that results in severe illness and hospitalization than a mild case, even
though a person with mild illness might be more likely to transmit infection to others because the
person might not be confined at home or in the hospital. This bias results in an inflated estimate
of disease severity in such measures as the death-to-case ratio. Second, health-care providers are
more likely to report cases when the disease is receiving media attention. This bias results in an
underestimate of the baseline incidence of disease after media attention wanes.
Both biases were operating in 1981 during the national epidemic of tampon-associated toxic
shock syndrome. Early reports indicated a death-to-case ratio much higher than the ratio
determined by subsequent studies, and reported cases declined more than incident cases after the
publicity waned.

Lack of timeliness. Lack of timeliness can occur at almost any step in the collection, analysis,
and dissemination of data on notifiable diseases. The reasons for the delays vary. Certain delays
are disease-dependent. For example, physicians cannot diagnose certain diseases until
confirmatory laboratory and other tests have been completed. Certain delays are caused by
cumbersome or inefficient reporting procedures. Delays in analysis are common when
surveillance is believed to be a rote function rather than as one that provides information for
action. Finally, delays at any step might culminate in delays in dissemination, with the result that
the medical and public health communities do not have the information they need to take prompt
action.

Limitations of Surveillance:

 Surveillance depends upon the reporting so underreporting could be a problem.

 Inconsistency in reporting
 Reporting may not be representative
 Takes time for data collection, analysis and interpretation
 Surveillance is on the tool of epidemiology it is not the solution to health problem.

Improving Notifiable Disease Surveillance

The preceding limitations of reporting systems demonstrate multiple steps that can be taken by a
local or state health department to improve reporting.

Improving awareness of practitioners. Most important, all persons who have a responsibility
to report must be aware of this responsibility. The health department should actively publicize
the list of notifiable diseases and the reporting mechanisms. Certain states send the reporting
requirements in a packet when a physician becomes licensed to practice in the state. Other state
health officials visit hospitals and speak at medical presentations or seminars to increase the
visibility of surveillance.

Incentives. Health-care providers might need services or therapeutic agents that are only
available from the health department, which might be able to use this need to obtain reports of
certain diseases. Services can include laboratory testing and consultation on diagnosis and
treatment of certain diseases. Agents might include immune globulin for human rabies and
hepatitis B and antitoxin for diphtheria and botulism. These services and agents might be
particularly effective incentives if they are available promptly and delivered in a professional,
authoritative manner.
Simplify reporting. Reporting should be as simple as possible. Health departments often accept
telephone reports or have toll-free telephone numbers. If paper forms are used, they should be
widely available and easy to complete, and they should ask only for relevant information. Certain
state health departments have arranged for electronic transfer of laboratory or other patient- or
case-related data; therefore, reporting is accomplished automatically at scheduled times or at the
push of a computer key.

Frequent feedback. The role of feedback cannot be overemphasized. Feedback can be written
(e.g., a monthly newsletter) or oral (e.g., updates at regular meetings of medical staff or at
rounds). The feedback should be timely, informative, interesting, and relevant to each reporter’s
practice. Feedback should include information about disease patterns and control activities to
increase awareness and to reinforce the importance of participating in a meaningful public health
activity.

Widening the net. Traditionally, surveillance for notifiable diseases has relied on reporting by
physicians. Almost every state now requires reporting of positive cultures or diagnostic tests for
notifiable diseases by commercial and hospital laboratories. For certain states, the number of
laboratory reports exceeds the number of reports from physicians, hospitals, clinics, and other
sources. Other health-care staff (e.g., infection control personnel and school nurses) can be used
as sources of data for surveillance. Another way to widen the net is to develop alternative
methods for conducting surveillance (e.g., using secondary sources of data). This method has
been used effectively for surveillance of influenza and certain injuries.

Shifting the burden. Another effective approach is to shift the burden for gathering data from
the health-care provider to the health department. In essence, this approach involves ongoing
surveys of providers to more completely identify cases of disease, and it has been demonstrated
to increase the number of cases and the proportion of identified-to-incident cases. Because health
department staff contact health-care providers regularly, this approach also promotes closer
personal ties among providers and health department staff. As with surveys in general, this
approach is relatively expensive, and its cost-effectiveness is not entirely clear. In practice, it is
usually limited to disease elimination programs, short-term intensive investigation and control
activities, or seasonal problems (e.g., certain arbovirus diseases).

Community diagnosis
According to WHO definition, it is “a quantitative and qualitative description of the health of
citizens and the factors which influence their health. It identifies problems, proposes areas for
improvement and stimulates action”.
How to conduct community diagnosis?
The process of community diagnosis involves four stages:
1. Initiation
2. Data collection and analysis
3. Diagnosis
4. Dissemination
1. Initiation In order to initiate a community diagnosis project, a dedicated committee or
working group should be set up to manage and coordinate the project. The committee should
involve relevant parties such as government departments, health professionals and non-
governmental organisations. At an early stage, it is important to identify the available budget and
resources to determine the scope of the diagnosis. Some of the common areas to be studied may
include health status, lifestyles, living conditions, socioeconomic conditions, physical and social
infrastructure, inequalities, as well as public health services and policies. Once the scope is
defined, a working schedule to conduct the community diagnosis, production and dissemination
of report should be set
. 2. Data collection and analysis The project should collect both quantitative and qualitative
data. Moreover, Population Census and statistical data e.g. population size, sex and age structure,
medical services, public health, social services, education, housing, public security and
transportation, etc. can provide background of the district. As for the community data, it can be
collected by conducting surveys through self-administered questionnaires, face to face
interviews, focus groups and telephone interviews. In order to ensure reliability of the findings,
an experienced organisation such as an academic institute can be employed for conducting the
study. The sampling method should be carefully designed and the sample size should be large
enough to provide sufficient data to draw reliable conclusions. Therefore, study results derived
can truly review the local community. Collected data can then be analysed and interpreted by
experts. Here are some practical tips on data analysis and presentation: - statistical information is
best presented as rates or ratios for comparison - trends and projections are useful for monitoring
changes over a time period for future planning - local district data can be compared with other
districts or the whole population - graphical presentation is preferred for easy understanding
Basic Principles of Healthy Cities : Community Diagnosis3
3. Diagnosis Diagnosis of the community is reached from conclusions drawn from the data
analysis. It should preferably comprise three areas: - health status of the community -
determinants of health in the community - potential for healthy city development
4. Dissemination The production of the community diagnosis report is not an end in itself,
efforts should be put into communication to ensure that targeted actions are taken. The target
audience for the community diagnosis includes policy-makers, health professionals and the
general public in the community. The report can be disseminated through the following channels:
- presentations at meetings of the health boards and committees, or forums organised for
voluntary organisations, local community groups and the general public - press release - thematic
events (such as health fairs and other health promotion programmes) It is important to realise
that Community Diagnosisis not an one-off project, but is part of a dynamic process leading to
health promotion in the community
A health intervention is an act performed for, with or on behalf of a person or population whose
purpose is to assess, improve, maintain, promote or modify health, functioning or health
conditions
IDENTIFICATION OF HEALTH INTERVENTION MEASURES

Vaccines

Vaccines are administered to individuals, usually before they have encountered the infectious
agent against which the vaccine is targeted, in order to protect them when they are naturally
exposed to the agent

Nutritional interventions

Food and nutrition are major determinants of human health and disease.

Education and behavior change

Some interventions directed at preventing disease are based solely upon changing human
behavior (for example, anti-smoking campaigns or campaigns to promote breastfeeding).

Screening

Population-based screening is an essential component of public health because it helps identify

individuals with asymptomatic diseases or unrecognized health risk factors. Screening has two
main goals: Identifying diseases in their early states and identifying risk states,

Supplementation

Supplementation of food or water of nutrients can reduce other diseases. Supplementation may
be required by law or voluntary. Some examples of interventions include: Iodised salt to
prevent goitre

Frequency measure
Mortality rates.
Mortality rate is measure of frequency on occurrence of death in a defined population during a
specified interval
 Types of mortality rates
There are several different mortality rates used to monitor the level of mortality in populations.
In humanitarian emergencies, the following are most commonly used:
A) Crude mortality rate. Counts all deaths. All causes. All ages and both sexes
Denominator includes entire population. All ages and both sexes
B) Age-specific mortality rate. Counts only deaths in specific age group
Usually calculated for children less than 5 years of age. Denominator includes only persons in
that age group
There are also mortality rates which are not really rates. They use live births as the denominator
instead of the actual group in which deaths are counted:
Infant mortality rate
Counts deaths in children less than 12 months of age, divides by number of live births in same
time period
Maternal mortality rate
Counts deaths in women due to pregnancy or child birth, divides by number of live births in
same time period
Under-5 mortality rate
Counts deaths in the first 5 years of life, divides by number of live births in the hypothetical
cohort of newborns.

Lesson 3: Measures of Risk

Section 3: Mortality Frequency Measures
Mortality rate

A mortality rate is a measure of the frequency of occurrence of death in a defined population

during a specified interval. Morbidity and mortality measures are often the same mathematically;
it’s just a matter of what you choose to measure, illness or death. The formula for the mortality
of a defined population, over a specified period of time, is:

Deaths occurring during a given time period

Size of the population among which
the deaths occurred

× 10 n

When mortality rates are based on vital statistics (e.g., counts of death certificates), the
denominator most commonly used is the size of the population at the middle of the time period.
In the United States, values of 1,000 and 100,000 are both used for 10n for most types of
mortality rates. Table 3.4 summarizes the formulas of frequently used mortality measures.

Table 3.4 Frequently Used Measures of Mortality

Measure Numerator Denominator 10n

Total number of deaths during a 1,000 or

Crude death rate Mid-interval population
given time interval 100,000

Number of deaths assigned to a

Cause-specific
specific cause during a given time Mid-interval population 100,000
death rate
interval

Number of deaths assigned to a Total number of deaths from all

Proportionate 100 or
specific cause during a given time causes during the same time
mortality 1,000
interval interval

Number of deaths assigned to a Number of new cases of same

Death-to-case ratio specific cause during a given time disease reported during the same 100
interval time interval

Number of deaths among children

Neonatal mortality Number of live births during the
< 28 days of age during a given time 1,000
rate same time interval
interval

Number of deaths among children

Postneonatal Number of live births during the
28–364 days of age during a given 1,000
mortality rate same time interval
time interval

Number of deaths among children

Infant mortality Number of live births during the
< 1 year of age during a given time 1,000
rate same time interval
interval

Maternal mortality Number of deaths assigned to Number of live births during the 100,000
rate pregnancy-related causes during a
 Measure Numerator Denominator 10n

given time interval same time interval

Crude mortality rate (crude death rate)

The crude mortality rate is the mortality rate from all causes of death for a population. In the
United States in 2003, a total of 2,419,921 deaths occurred. The estimated population was
290,809,777. The crude mortality rate in 2003 was, therefore, (2,419,921 ⁄ 290,809,777) ×
100,000, or 832.1 deaths per 100,000 population.(8)

Cause-specific mortality rate

The cause-specific mortality rate is the mortality rate from a specified cause for a population.
The numerator is the number of deaths attributed to a specific cause. The denominator remains
the size of the population at the midpoint of the time period. The fraction is usually expressed per
100,000 population. In the United States in 2003, a total of 108,256 deaths were attributed to
accidents (unintentional injuries), yielding a cause-specific mortality rate of 37.2 per 100,000
population.(8)

Age-specific mortality rate

An age-specific mortality rate is a mortality rate limited to a particular age group. The numerator
is the number of deaths in that age group; the denominator is the number of persons in that age
group in the population. In the United States in 2003, a total of 130,761 deaths occurred among
persons aged 25–44 years, or an age-specific mortality rate of 153.0 per 100,000 25–44 year
olds.(8) Some specific types of age-specific mortality rates are neonatal, postneonatal, and infant
mortality rates, as described in the following sections.

Infant mortality rate

The infant mortality rate is perhaps the most commonly used measure for comparing health
status among nations. It is calculated as follows:

Number of deaths among children < 1 year of age reported during a given time period

Number of live births reported during the

same time period

× 1,000

The infant mortality rate is generally calculated on an annual basis. It is a widely used measure
of health status because it reflects the health of the mother and infant during pregnancy and the
year thereafter. The health of the mother and infant, in turn, reflects a wide variety of factors,
including access to prenatal care, prevalence of prenatal maternal health behaviors (such as
alcohol or tobacco use and proper nutrition during pregnancy, etc.), postnatal care and behaviors
(including childhood immunizations and proper nutrition), sanitation, and infection control.

Is the infant mortality rate a ratio? Yes. Is it a proportion? No, because some of the deaths in the
numerator were among children born the previous year. Consider the infant mortality rate in
2003. That year, 28,025 infants died and 4,089,950 children were born, for an infant mortality
rate of 6.951 per 1,000.8 Undoubtedly, some of the deaths in 2003 occurred among children born
in 2002, but the denominator includes only children born in 2003.

Is the infant mortality rate truly a rate? No, because the denominator is not the size of the mid-
year population of children < 1 year of age in 2003. In fact, the age-specific death rate for
children < 1 year of age for 2003 was 694.7 per 100,000.(8) Obviously the infant mortality rate
and the age-specific death rate for infants are very similar (695.1 versus 694.7 per 100,000) and
close enough for most purposes. They are not exactly the same, however, because the estimated
number of infants residing in the United States on July 1, 2003 was slightly larger than the
number of children born in the United States in 2002, presumably because of immigration.

Neonatal mortality rate

The neonatal period covers birth up to but not including 28 days. The numerator of the neonatal
mortality rate therefore is the number of deaths among children under 28 days of age during a
given time period. The denominator of the neonatal mortality rate, like that of the infant
mortality rate, is the number of live births reported during the same time period. The neonatal
mortality rate is usually expressed per 1,000 live births. In 2003, the neonatal mortality rate in
the United States was 4.7 per 1,000 live births.(8)

Postneonatal mortality rate

The postneonatal period is defined as the period from 28 days of age up to but not including 1
year of age. The numerator of the postneonatal mortality rate therefore is the number of deaths
among children from 28 days up to but not including 1 year of age during a given time period.
The denominator is the number of live births reported during the same time period. The
postneonatal mortality rate is usually expressed per 1,000 live births. In 2003, the postneonatal
mortality rate in the United States was 2.3 per 1,000 live births.(8)

Maternal mortality rate

The maternal mortality rate is really a ratio used to measure mortality associated with pregnancy.
The numerator is the number of deaths during a given time period among women while pregnant
or within 42 days of termination of pregnancy, irrespective of the duration and the site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not
from accidental or incidental causes. The denominator is the number of live births reported
during the same time period. Maternal mortality rate is usually expressed per 100,000 live births.
In 2003, the U.S. maternal mortality rate was 8.9 per 100,000 live births.(8)

Sex-specific mortality rate

 A sex-specific mortality rate is a mortality rate among either males or females. Both numerator
and denominator are limited to the one sex.

Race-specific mortality rate

A race-specific mortality rate is a mortality rate related to a specified racial group. Both
numerator and denominator are limited to the specified race.

Combinations of specific mortality rates

Mortality rates can be further stratified by combinations of cause, age, sex, and/or race. For
example, in 2002, the death rate from diseases of the heart among women ages 45–54 years was
50.6 per 100,000.(9) The death rate from diseases of the heart among men in the same age group
was 138.4 per 100,000, or more than 2.5 times as high as the comparable rate for women. These
rates are a cause-, age-, and sex-specific rates, because they refer to one cause (diseases of the
heart), one age group (45–54 years), and one sex (female or male).

EXAMPLE: Calculating Mortality Rates

Table 3.5 provides the number of deaths from all causes and from accidents (unintentional
injuries) by age group in the United States in 2002. Review the following rates. Determine what
to call each one, then calculate it using the data provided in Table 3.5.

a. Unintentional-injury-specific mortality rate for the entire population

This is a cause-specific mortality rate.

Rate =

number of unintentional injury deaths in the entire population

estimated midyear population

× 100,000

= (106,742 ⁄ 288,357,000) × 100,000

= 37.0 unintentional-injury-related deaths per 100,000 population

b. All-cause mortality rate for 25–34 year olds

This is an age-specific mortality rate.

Rate =
 number of deaths from all causes among 25–34 year olds

estimated midyear population of 25–34 year olds

× 100,000

= 103.6 deaths per 100,000 25–34 year olds

c. All-cause mortality among males

This is a sex-specific mortality rate.

Rate =

number of deaths from all causes among males

estimated midyear population of males

× 100,000

= (1,199,264 ⁄ 141,656,000) × 100,000

= 846.6 deaths per 100,000 males

d. Unintentional-injury specific mortality among 25 to 34 year old males

This is a cause-specific, age-specific, and sex-specific mortality rate

Rate =

number of unintentional injury deaths among 25–34 year old males

estimated midyear population of 25–34 year old males

× 100,000

= (9,635 ⁄ 20,203,000) × 100,000

= 47.7 unintentional-injury-related deaths per 100,000 25–34 year olds

 Ratio

Definition of ratio

A ratio is the relative magnitude of two quantities or a comparison of any two values. It is
calculated by dividing one interval- or ratio-scale variable by the other. The numerator and
denominator need not be related. Therefore, one could compare apples with oranges or apples
with number of physician visits.

Method for calculating a ratio

Number or rate of events, items, persons,

etc. in one group

Number or rate of events, items, persons,

etc. in another group
After the numerator is divided by the denominator, the result is often expressed as the result “to
one” or written as the result “:1.”

Note that in certain ratios, the numerator and denominator are different categories of the same
variable, such as males and females, or persons 20–29 years and 30–39 years of age. In other
ratios, the numerator and denominator are completely different variables, such as the number of
hospitals in a city and the size of the population living in that city.

EXAMPLE: Calculating a Ratio — Different Categories of Same Variable

Between 1971 and 1975, as part of the National Health and Nutrition Examination Survey
(NHANES), 7,381 persons ages 40–77 years were enrolled in a follow-up study.(1) At the time
of enrollment, each study participant was classified as having or not having diabetes. During
1982–1984, enrollees were documented either to have died or were still alive. The results are
summarized as follows.

Participant Original Dead at Follow-

Enrollment Up
(1971–1975) (1982–1984)
Diabetic men 189 100
Nondiabetic men 3,151 811
Diabetic women 218 72
Nondiabetic 3,823 511
women
Of the men enrolled in the NHANES follow-up study, 3,151 were nondiabetic and 189 were
diabetic. Calculate the ratio of non-diabetic to diabetic men.
 Ratio = 3,151 ⁄ 189 × 1 = 16.7:1

Properties and uses of ratios

 Ratios are common descriptive measures, used in all fields. In epidemiology, ratios are used
as both descriptive measures and as analytic tools. As a descriptive measure, ratios can
describe the male-to-female ratio of participants in a study, or the ratio of controls to cases
(e.g., two controls per case). As an analytic tool, ratios can be calculated for occurrence of
illness, injury, or death between two groups. These ratio measures, including risk ratio
(relative risk), rate ratio, and odds ratio, are described later in this lesson.
 As noted previously, the numerators and denominators of a ratio can be related or unrelated.
In other words, you are free to use a ratio to compare the number of males in a population
with the number of females, or to compare the number of residents in a population with the
number of hospitals or dollars spent on over-the-counter medicines.
 Usually, the values of both the numerator and denominator of a ratio are divided by the
value of one or the other so that either the numerator or the denominator equals 1.0. So the
ratio of non-diabetics to diabetics cited in the previous example is more likely to be
reported as 16.7:1 than 3,151:189.

EXAMPLES: Calculating Ratios for Different Variables

Example A: A city of 4,000,000 persons has 500 clinics. Calculate the ratio of clinics per
person.
500 ⁄ 4,000,000 × 10n = 0.000125 clinics per person

To get a more easily understood result, you could set 10n = 104 = 10,000. Then the ratio
becomes:

0.000125 × 10,000 = 1.25 clinics per 10,000 persons

You could also divide each value by 1.25, and express this ratio as 1 clinic for every 8,000
persons.

Example B: Delaware’s infant mortality rate in 2001 was 10.7 per 1,000 live births.(2) New
Hampshire’s infant mortality rate in 2001 was 3.8 per 1,000 live births. Calculate the ratio of the
infant mortality rate in Delaware to that in New Hampshire.

10.7 ⁄ 3.8 × 1 = 2.8:1

Thus, Delaware’s infant mortality rate was 2.8 times as high as New Hampshire’s infant
mortality rate in 2001.

A commonly used epidemiologic ratio: death-to-case ratio

Death-to-case ratio is the number of deaths attributed to a particular disease during a specified
period divided by the number of new cases of that disease identified during the same period. It is
used as a measure of the severity of illness: the death-to-case ratio for rabies is close to 1 (that is,
almost everyone who develops rabies dies from it), whereas the death-to-case ratio for the
common cold is close to 0.

For example, in the United States in 2002, a total of 15,075 new cases of tuberculosis were
reported.(3During the same year, 802 deaths were attributed to tuberculosis. The tuberculosis
death-to-case ratio for 2002 can be calculated as 802 ⁄ 15,075. Dividing both numerator and
denominator by the numerator yields 1 death per 18.8 new cases. Dividing both numerator and
denominator by the denominator (and multiplying by 10n = 100) yields 5.3 deaths per 100 new
cases. Both expressions are correct.

Note that, presumably, many of those who died had initially contracted tuberculosis years earlier.
Thus many of the 802 in the numerator are not among the 15,075 in the denominator. Therefore,
the death-to-case ratio is a ratio, but not a proportion.

Ratio = 179 ⁄ (341 − 179) × 1

= 179 ⁄ 162
= 1.1 to 1 female-to-male ratio

Conversely, if a ratio’s numerator and denominator together make up a whole population, the
ratio can be converted to a proportion. You would add the ratio’s numerator and denominator to
form the denominator of the proportion, as illustrated in the NHANES follow-up study examples
(provided earlier in this lesson).

A specific type of epidemiologic proportion: proportionate mortality

Proportionate mortality is the proportion of deaths in a specified population during a period of

time that are attributable to different causes. Each cause is expressed as a percentage of all
deaths, and the sum of the causes adds up to 100%. These proportions are not rates because the
denominator is all deaths, not the size of the population in which the deaths occurred. Table 3.1
lists the primary causes of death in the United States in 2003 for persons of all ages and for
persons aged 25–44 years, by number of deaths, proportionate mortality, and rank.

Rate

Definition of rate

In epidemiology, a rate is a measure of the frequency with which an event occurs in a defined
population over a specified period of time. Because rates put disease frequency in the perspective
of the size of the population, rates are particularly useful for comparing disease frequency in
different locations, at different times, or among different groups of persons with potentially
different sized populations; that is, a rate is a measure of risk.

To a non-epidemiologist, rate means how fast something is happening or going. The

speedometer of a car indicates the car’s speed or rate of travel in miles or kilometers per hour.
This rate is always reported per some unit of time. Some epidemiologists restrict use of the term
rate to similar measures that are expressed per unit of time. For these epidemiologists, a rate
describes how quickly disease occurs in a population, for example, 70 new cases of breast cancer
per 1,000 women per year. This measure conveys a sense of the speed with which disease occurs
in a population, and seems to imply that this pattern has occurred and will continue to occur for
the foreseeable future. This rate is an incidence rate, described in the next section, starting on
page 3-13.

Other epidemiologists use the term rate more loosely, referring to proportions with case counts in
the numerator and size of population in the denominator as rates. Thus, an attack rate is the
proportion of the population that develops illness during an outbreak. For example, 20 of 130
persons developed diarrhea after attending a picnic. (An alternative and more accurate phrase for
attack rate is incidence proportion.) A prevalence rate is the proportion of the population that
has a health condition at a point in time. For example, 70 influenza case-patients in March 2005
reported in County A. A case-fatality rate is the proportion of persons with the disease who die
from it. For example, one death due to meningitis among County A’s population. All of these
measures are proportions, and none is expressed per units of time. Therefore, these measures are
not considered “true” rates by some, although use of the terminology is widespread.

Prevalence
The prevalence represents existing cases of a disease and can be seen as a measure of disease
status; it is the proportion of people in a population having a disease:

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The prevalence is often useful as it reflects the burden of a disease in a certain population. This is
not limited to burden in terms of monetary costs; it also reflects burden in terms of life
expectancy, morbidity, quality of life, or other indicators. Knowledge of the burden of disease
can help decision makers to determine where investments in health care should be targeted. For
instance, the prevalent number of end-stage renal disease (ESRD) patients predicts the need for
dialysis facilities and the related costs.

As an example, in a study that was published in 2007, Zelmer [2 ]assessed the economic burden
of ESRD in Canada. A prevalence-based approach was used to estimate direct health care costs
associated with ESRD. The author reported that by the end of the year 2000, there were an
estimated 24,921 Canadians living with ESRD and the total direct costs of ESRD in that year
were 1,273 million dollar.

Incidence
While the prevalence represents the existing cases of a disease, the incidence reflects the number
of new cases of disease within a certain period and can be expressed as a risk or an incidence
rate.

Risk
The risk is the probability that a subject within a population will develop a given disease, or
other health outcome, over a specified follow-up period. It can be calculated by dividing the
number of subjects developing the disease over a certain period by the total number of subjects
followed over that period:

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This risk can be interpreted as an estimation of the risk of disease in an individual subject.
However, to interpret a risk appropriately, it is necessary to know the time period to which it
applies. Without the definition of a time period, a risk is a meaningless value.

This can be illustrated by means of the following example: Ojo et al. [3] studied patient and
allograft outcomes among African-American kidney transplant recipients with ESRD as a result
of sickle cell nephropathy when compared to all other causes of ESRD. They identified 22,647
patients who received a renal transplant between 1984 and 1996. Of them, 82 had sickle cell
nephropathy. The risk of acute rejection in the 1st year after transplantation was 43.9% in the
recipients with sickle cell nephropathy compared to 41.9% in those with other causes of ESRD.

One can imagine that without reporting the time period to which they applied, the rejection rates
of 43.9 and 41.9% could not have been interpreted. A risk of rejection of 43.9% within 1 week
would have been extremely high, while the same risk over a period of 50 years would have been
surprisingly low.

For the calculation of a risk, a few assumptions need to be made. First, because the risk reflects
new cases of disease, all subjects should be free of this disease at the start of the follow-up
period. Second, all subjects should be followed over the total period of time during which the
risk is measured. This second requirement can lead to a few problems, especially in studies with
a relatively long follow-up period. The longer the follow-up period is, the higher is the chance
subjects will become lost to follow-up. In addition, subjects can drop out of the study because of
causes that ‘compete’ with the outcome of interest. For example, if one aims to study death of
cardiovascular causes, death of any other cause, e.g. a car accident, can be considered as a
competing risk. Both loss to follow-up and competing risks can lead to an underestimation of the
risk, because the subjects leaving the study are not any longer able to experience the event of
interest and will therefore not be able to add to the numerator in the formula.

Also in the case of a dynamic population, calculating the risk is frequently impossible. Whereas
in a ‘closed’ cohort all measures of disease occurrence can be applied, it is problematic to
measure risk directly in an ‘open’ cohort, where new people are added during the follow-up
period [4]. These situations illustrate that it in many cases it is better to choose an alternative
approach to express incidence, i.e. the incidence rate.

Incidence Rate
The second measure of disease frequency that expresses incidence is the incidence rate. It can be
calculated by dividing the number of subjects developing a disease by the total time at risk for all
people to get the disease. The denominator of this formula includes a measure of time instead of
just a number of subjects. The incidence rate should therefore be interpreted as an instantaneous
concept, like speed:

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Like for the risk, one assumes for the calculation of the incidence rate that all subjects are free of
the disease of interest at the start of the study. However, an important advantage of the incidence
rate over the risk is that it is not required for subjects to complete the total follow-up time and
only the actual time at risk is taken into account. Figure 1 shows an example of the calculation of
the incidence rate. Suppose we study the incidence rate of vascular access infection in
haemodialysis (HD) patients in a year and we would have diagnosed a number of episodes of
vascular access infection in 10 HD patients. We would then need to calculate the total time at
risk; in this case the total time on HD. Figure 1 shows that the 10 patients together were at risk
for 89 patient-months. In this period, there were 4 of such episodes. The incidence rate of HD
vascular access infection would therefore be 4/89 = 0.045 per patient-month, or 4/7.42 = 0.54 per
patient-year. Assuming that each HD station in a dialysis department is occupied during the full
year (by predecessors and successors of the patients shown in fig. 1), one could also calculate the
incidence rate of vascular access infection on the level of HD station instead of on patient level.
In this case, one would simply need to divide the total number of vascular access infections by
the time when the HD stations were occupied (1 year per station).

Fig. 1
Example of calculating the incidence rate: time at risk for vascular access infection in 10 HD
patients. Tx = Renal transplantation.

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In larger studies the incidence rate is presented similarly, as is shown in the following example:
in 1999, Chow et al. [5] published a study on the rising incidence of renal cell cancer by age,
gender, and race in the United States. The authors collected data of patients diagnosed as having
kidney cancer between 1975 and 1995 in 9 geographic areas covered by tumour registries. They
reported incidence rates for renal cell carcinoma in white men, white women, black men and
black women of 9.6, 4.4, 11.1 and 4.9/100,000 person-years, respectively.

Under conditions in which rates do not change with time (a steady state), the incidence rate can
be interpreted as the reciprocal of the average time until an event occurs, also called the waiting
time. For example, in the calculation of the incidence rate of vascular access infections in HD
patients, the average waiting time for such an episode to occur would be 1/0.54 = 1.85 years.

When calculated over a short period of time, the risk and the incidence rate will be rather similar,
because the influence of loss to follow-up and competing risks which may flaw risk will only be
small.

Incidence versus Prevalence

Factors that influence the prevalence are the number of incident cases, the deaths, and the
recoveries, as is depicted in figure 2. Given a steady state, the prevalence approximately equals
the product of the incidence rate and the mean duration of disease. This can be illustrated by the
examples of tetanus and ESRD. Tetanus is an acute, rare, and often fatal disease caused by the
bacteria Clostridium tetani, leading to rapid death resulting in short disease duration. As a result,
its prevalence in the general population will be extremely low at any point in time. ESRD, on the
other hand, has a relatively low incidence rate, but in comparison to tetanus its survival is much
higher, at least in developed countries. Its average disease duration is much longer; therefore, its
prevalence is much higher compared to that of tetanus. Accordingly, an increase in prevalence
could be the consequence of a higher incidence of ESRD, of an improved survival, or of a
combination of both.