Measures of disease occurrence

The Epidemiologic Approach

In very simple terms, the epidemiologist:

■ Counts cases or health events, and describes them in terms of
time, place, and person.
■ Divides the number of cases by an appropriate denominator to
calculate rates.
■ Compares these rates over time or for different groups of
people.
1. Before counting cases, the epidemiologist must decide what a case is.
This is done by developing a case definition.
2. Then, using this case definition, the epidemiologist finds and collects
information about the case-patients. The epidemiologist then performs
descriptive epidemiology.
3. To calculate the disease rate, the epidemiologist divides the
number of cases by the size of the population.
4. Finally, to determine whether this rate is greater than what one would
normally expect, and if so to identify factors contributing to this
increase, the epidemiologist compares the rate from this population to
the rate in an appropriate comparison group, using analytic
epidemiology.
1-Case definition:
What is the value of case definition?
1. Use of an agreed-upon standard case definition ensures that every case is
equivalent, regardless of when or where it occurred, or who identified it.
2. The number of cases or rate of disease identified in one time or place can be
compared with the number or rate from another time or place.

To ensure that all health departments in the United States use the same case
definitions for surveillance, the Council of State and Territorial
Epidemiologists (CSTE), CDC, and other interested parties have adopted
standard case definitions for the notifiable infectious diseases. These
definitions are revised as needed.
Components of a case definition for
outbreak investigations
■ A case definition consists of clinical criteria:
 Confirmatory laboratory tests, if available, and/or
 Combinations of signs and symptoms and other findings.
 Case definitions used during outbreak, investigations are
more likely to specify limits on time, place, and/or person
than those used for surveillance.
For example:
• Contrast the case definition used for surveillance of listeriosis with
the case definition used during an investigation of a listeriosis
outbreak in North Carolina in 2000.
• Both the national surveillance case definition and the outbreak case
definition require a clinically compatible illness and laboratory
confirmation of Listeria monocytogenes from a normally sterile site,
but the outbreak case definition adds restrictions on time and place,
reflecting the scope of the outbreak.
• Many case definitions, such as that shown for listeriosis, require
laboratory confirmation. This is not always necessary, however; in
fact, some diseases have no distinctive laboratory findings.
 Listeriosis — Surveillance Case
Definition
Listeriosis — Outbreak
• Clinical description
Investigation
 stillbirth, listeriosis of the newborn,
• Case definition
meningitis, bacteremia, or localized
 Clinically compatible illness
infections.
with L. monocytogenes isolated
• Laboratory criteria for diagnosis
 From a normally sterile site.
 Isolation of L. monocytogenes
 In a resident of Winston-Salem,
from a normally sterile site (e.g.,
North Carolina.
blood or cerebrospinal fluid or, less
 With onset between October 24,
commonly, joint, pleural, or
2000 and January 4, 2001.
pericardial fluid).
• Case classification
 Confirmed: a clinically compatible
case that is laboratory confirmed.
Criteria in case definitions
A case definition may have several sets of criteria, depending on
how certain the diagnosis is. Suspected, probable, or confirmed
case is one of example.
■ For example, during an investigation of a possible case or
outbreak of MERS-CoV, a person might be classified as
suspected or probable case while waiting for the laboratory
results to become available. Once the laboratory provides the
report, the case can be reclassified as either confirmed or “not
a case.”
 Modifying case definitions
Case definitions can also change over time as more information is obtained.
■ For example:
• The first case definition for SARS, based on clinical symptoms and either contact
with a case or travel to an area with SARS transmission, was published in CDC’s
Morbidity and Mortality Weekly Report (MMWR) on March 21, 2003.
• On March 29, after a novel corona virus was determined to be the causative agent,
an interim surveillance case definition was published that included laboratory
criteria for evidence of infection with the SARS-associated corona virus.
• By June, the case definition had changed several more times.
• A revised and much more complex case definition was published in December
2003.
Variation in case definitions
Case definitions may also vary according to the purpose for
classifying the occurrences of a disease.
 A sensitive case definition (broad or loose), in the hope of
capturing most or all of the true cases.
 For example, health officials need to know as soon as possible
if anyone has symptoms of plague or anthrax. For such rare but
potentially severe communicable diseases, it is important to
identify every possible case.
 A specific case definition (strict), an investigator studying the
causes of a disease outbreak usually wants to be certain that any
person included in a study really had the disease.

 For example, in an outbreak of Salmonella infection, the

investigators would be more likely to identify the source of the
infection if they included only persons who were confirmed to
have been infected with that organism, rather than including
anyone with acute diarrhea, because some persons may have had
diarrhea from a different cause.
2- The count:
The count is "the number of cases of a disease or other health
phenomenon being studied."
• The simplest/ most basic / most frequently performed measure of
disease occurrence in epidemiology is a simple count of affected
individuals.
• Such information is useful for public health planners and administrators
for proper allocation of health care resources in a particular community.
 For examples: number of persons had psychiatric crises, cases of
influenza in Alabama in Jan 2010.
 location New cases of disease Period population
City A 20 1999 100
City B 100 1999 1000

• However, the number of cases of a disease may vary from place to

place according to the number of people in each place. Thus, we
have to relate number of cases of a disease to the population from
which these cases come.

• The key in epidemiology is relating the frequency (the numerator) to

an appropriate population (the denominator) in order to describe and
compare groups in a meaningful and useful way.
Annual rate of occurrence:
City A: 20/100 = 1/5
City B: 100/1000 = 1/10
 
 Such measures allow direct comparisons of disease
frequencies in two or more groups of individuals.
Frequency measures:

■ Frequency measures compare one part of the distribution to

another part of the distribution, or to the entire distribution.
■ We express disease frequency not as absolute number, but a
related number.
■ Common frequency measures are ratios, proportions, and
rates.
All three frequency-measures have the same basic form:
Ratio

■ A ratio quantifies "the magnitude of one occurrence or

condition to another".
■ Forms of writing ratio:
x:y or x/y
Properties and uses of ratios:
1. Ratio is the relationship between two numbers (one is divided by the
other).
2. Those included in the numerator are not included in the denominator.
3. It does not relate to a particular time.
4. 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.
5. The numerators and denominators of a ratio can be related (the
numerator and denominator are different categories of the same
variable); such as:
- The number of males and females, persons 20–29 years and 30–
39 years of age.

6. 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.

7. 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.
Examples:
Number of males
Sex Ratio =
Number of females

Risk of disease in one group (exposed)

Risk Ratio =
Risk of disease in another group (unexposed)
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.
 Original Enrollment Dead at Follow-Up
(1971–1975) (1982–1984)

Diabetic men 189 100

Nondiabetic men 3,151 811

Diabetic women 218 72

Nondiabetic
3,823 511
women
1. Calculate the ratio of non-diabetic to diabetic men.
Ratio = 3,151 ⁄ 189 × 1 = 16.7:1
• Calculate the ratio of non-diabetic to diabetic women.
• Calculate the ratio of non-diabetic men to diabetic
women.
Proportion:

■ A proportion quantifies the "occurrences in relation to the

populations in which these occurrences take place".
■ It is a specific type of ratio in which the numerator is included
in the denominator and the result is expressed as a percentage.
■ a / a+b
Properties and uses of proportions:
1. A proportion is the comparison of a part to the whole.
2. In a proportion, the numerator must be included in the denominator.
– Thus, the number of apples divided by the number of oranges is not a
proportion, but the number of apples divided by the total number of
fruits of all kinds is a proportion.
3. A proportion (also ratio and rate) may be expressed as a decimal,
a fraction, or a percentage;
– The statements “one fifth of the residents became ill” and “twenty
percent of the residents became ill” are equivalent.
4. It also may be expressed as a number between 0 and 1.
5. In epidemiology, proportions are used most often as descriptive
measures.
– The proportion of children in a village vaccinated against measles.
– The proportion of persons who developed illness among all passengers
of a cruise ship.
6. Proportions are also used to describe the amount of disease that can be
attributed to a particular exposure.
– For example, on the basis of studies of smoking and lung cancer,
public health officials have estimated that greater than 90% of the lung
cancer cases that occur are attributable to cigarette smoking.
Examples Number of male births
Proportion of male births =
Total number of births
Proportion of persons with a specific disease (usually termed: prevalence) =

Number of persons with a specific disease

Total population
Example: distribution of cases of type I diabetes:
Age 0 - 4 = 70 cases
Age 5 - 9 = 73 cases
Age 10-14 = 75 cases
Total = 218
70
= 0.32 or 32% of all children who developed
70+73+75 diabetes were less than age of 5.
Rate:
■ Rate is "a special form of proportion that includes time".
■ It is a special ratio (all rates are ratios but not all ratios are rates), where a
number of individuals within a defined group with the outcome of
interest (numerator) is divided by the number of individuals enumerated
in the population (denominator) per unit length of time.
• i.e. rate is the number of persons (diseased or dead) per unit of population
per unit of time.

■ a* / a+b
■a* = the frequency of events during a certain time period
Number of events (disease or death) in a specified period X 10n
Number of population at risk of these events in the same period

It contains the following elements:

1. Count of all events of interest (i.e. disease).
2. Unit size of a population.
3. Time period in which an event occurs.
Properties and uses of rates:

1. The numerator is a subset of the denominator.

2. Rate is the most important epidemiological tool used for measuring
diseases.
3. It is the measure that expresses probability or risk of disease in a defined
population over a specified period of time; hence, it is considered a basic
measure of disease occurrence.
4. 10n is used to get a whole number to avoid fraction and for ease of
interpretation.
5. The rate is multiplied by 100, 1,000, 10,000 or 100,000.
6. 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 rate is an incidence rate, for example; the number of newly

diagnosed pneumonia cases in 1999 is 5 per 1000 for children
under five years old.
Another important rate:
Annual death count
Crude death (mortality) rate = X 1,000
Reference population (during midpoint of year)

Example: death count in U.S. during 1990 was: 2,148,463

U.S. population on June 30, 1990 was: 246,709,873
2,148,463
Crude death rate = X 1,000 = 8.64 per 1,000
246,709,873
What does that mean?
It means that over the course of a year:
1. About 9 persons per 1,000 died.
2. About 864 persons per 100,000 died.
3. The risk of dying was about 0.9 %.
EXAMPLE: Calculating a Ratio,
proportion and rate:
■ 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.
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:

Original Enrollment Dead at Follow-Up

1971-1975 1982-1984
Diabetic men 189 100
Non-diabetic men 3,151 811
Diabetic women 218 72
Non-diabetic women 3,823 511
Q1:- Of the men enrolled in the NHANES follow-up
study, 3,151 were non-diabetic and 189 were diabetic.
Calculate the ratio of non-diabetic to diabetic men.

Ratio = (3,151 / 189) X 1 = 16.7:1

= 17:1
Q2:- Calculate the proportion of men who were
diabetics.

– Numerator = 189 diabetic men

– Denominator = Total number of men = (189 + 3,151) = 3,340
Proportion = (189 / 3,340) X 100 = 5.66% = 5.7%
Q3:- Calculate the death rate of women who were diabetic in the
period 1982 – 1984:

– Numerator = 72 dead diabetic women

– Denominator = Total number of women = (218 + 3,823) = 4,041
Death rate = (72 / 4,041) X 100 = 1.78 % = 1.8%
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