# Measurement in Epidemiology: Frequency, Association, and Impact

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1 Measurement in Epidemiology: Frequency, Association, and Impact Mayfong Mayxay M.D., Ph.D. (Trop Med) GFMER - WHO - UNFPA - LAO PDR Training Course in Reproductive Health Research Vientiane, 12 October 2009

2 Types of Epidemiologic Measures 1. Measures of disease frequency 2. Measures of association 3. Measures of potential impact

3 Rationale 1. Careful & accurate measurement of disease occurrence (morbidity & mortality): constitutes fundamental basis of studies 2. Studies are designed to: - describe & compare disease trends; - identify disease determinants; - evaluate public health interventions aimed at controlling health problems

4 Measures of Disease Frequency Measures of disease frequency in mathematical quantity - Count - Proportion (percentage) - Rate - Ratio Measures of disease frequency in epidemiology - Prevalence - Incidence

5 Importance of Denominator a Numerator b Denominator Example 1: 500 cases of dengue fever in Vientiane 120 cases of dengue fever in Phongsaly Which one is more infected? Vientiane: 200/800,000 = 0.25/1,000 Phongsaly: 120/300,000 = 0.4/1,000

6 Example 2: Dengue outbreak in Savannakhet No. cases Year Is the situation worse? Answer: depends on population size, difference in reporting method (more sensible), definition of case!!!

7 Count, Proportion, Rate, Ratio Counts: Simplest & most basic measure - absolute number of persons who have disease or characteristic of interest. Useful for health planners & administrators: for allocation of resources (e.g. quantity of ORS needed by diarrheal cases) Count of No. cases of a disease, is used for surveillance of infectious disease for early detection of outbreaks.

8 Limited values of counts Number of persons with characteristic, e.g., cases of dengue hemorrhagic fever, depends on the size of the population at risk of the disease in an area. The bigger this group, the higher is the expected number of cases. The duration of observation also affects the frequency of cases; the longer the observation period, the more cases can occur. Count does not contain these elements!

9 Proportion (percentage, frequency) Proportion: + a included in the denominator a + No measurement unit; > 0 to < 1 a + b + Often expressed as % Example: From 7,999 females aged y, 2,496 use modern contraceptive methods. The proportion of those who use modern contraceptive methods = 2,496 / 7,999 x 100 = 31.2%

10 Rate Definition: Frequency of events, that occur in a defined time period, divided by the average population of risk. Rate = Numerator Denominator x Constant multiplier Number of deaths Crude death rate = (defined place and time period) Mid-period population x 1000 (same place and population)

11 Ratio Ratio: A fraction in which the numerator is not part of the denominator. a b a and b are two mutually exclusive frequency Example: - Number of hospital beds per 100,000 - Male and female dengue infection ratio = 70/35 or 2 males to one female (2 : 1)

12 Mortality, Fatality, Death Mortality rate: Death of a particular disease/event in the total population (e.g., maternal mortality) Number of pregnancy related death (defined place and time period) Number of live birth (same place and time period) x 100,000 Maternal mortality rate in Laos in 2000 ~ 530/100,000 Fatality rate: Mortality among cases of a particular disease Death rate: Mortality of all diseases among the total population

13 Commonly Used Rates for Population Study Agespecific death rate Number of death in a particular age group = (defined place and time period) Mid-period population x 1,000 (same age group, place and time period) Cause specific death rate = Number of death due to a particular cause (defined place and time period) Mid-period population (same place and time period) x 1,000

14 Infant mortality rate Number of death to infants <1 year of age = (defined place and time period) Number of live births x 1,000 (same place and time period) Infant mortality rate in Laos in 2005 ~ 70 / 1,000 Peri-natal mortality rate = Number of stillbirth (defined place and time period) Number of stillbirth (same place and time period) + + Number of deaths to infants <7 days of age (same place and time period Number of live births (same place and time period) x 1,000

15 Prevalence Number of existing cases of disease Proportion of individuals in a population with disease or condition at a specific point of time Prevalence = No. of cases observed at time t Total No. of individuals at time t

16 Example of Prevalence The prevalence of hypertension (systolic BP > 95 mmhg) on May 1-2, 2009 in Lao men aged years in Xienglairkhok village was: 276 persons with systolic BP > 95 mmhg 1,853 Lao men aged years at the time of survey x 100 = 15%

17 Prevalence divided into two types: /01/ /12/2009 * Point prevalence - 01/01/2009: case No. 2, 4, 5-31/12/2009: case No. 6, 7, 10 * Period prevalence between 01/01-31/12/2009: Case No. 2, 3, 4, 5, 6, 7, 9, 10

18 Incidence Measures of new cases of disease that develop in a population during a specified period of time 2 types of incidence 1.Cumulative incidence (incidence) 2.Incidence rate = incidence density

19 Cumulative Incidence (CI) = Incidence No. of individuals who get the disease during a certain period CI = No. of individuals in the population at the beginning of the period A proportion Has no dimension Varies between 0 and 1

20 Example of Cumulative Incidence The population statistic of Lab Lair District in 2001 revealed that there were 5,572 women aged years who were sex workers. Based on the record of CHAS, among those women, 45 were HIV + ve during What is the cumulative incidence of HIV + ve among those women during a period of 4 years? Cumulative incidence = 45 / 5,572 = or 0.8%

21 Incidence Rate or Density (ID) No. of new cases that occur during a calendar period ID = Amount of pop-time contributed by the observed candidate pop. During that period (time at risk) Not a proportion Has dimension (unit of ID is time) Varies between 0 to infinity

22 Example of Incidence Density In 2003, the number of new cases of STI was 29 among the men aged years in Lab Leu District. The personyears was 41,532 among that group of people. What is the incidence density or incidence rate of STI + ve among those people? Incidence density = 29 / 41,532 person-years = /year

23 Prevalence vs Incidence Incidence Prevalence Death or cure

24

25 Measures of Association Statistical relationship between two or more events, characteristics, or other variables Statistical relationship between exposure and disease Association is not causation!

26 Absolute Risk difference Relative Risk ratios exposed - unexposed Odds ratios exposed / unexposed

27 The relative risk of myocardial infarction in men compared with women is : 5 Risk ratio = Risk men Risk women = 5 cases/1000 PY 1 case/1000 PY = 5 The absolute risk difference between men and women is : 4 cases/1000 PY 5 cases/1000 PY - 1 case/1000 PY = 4 cases/1000 PY

28 Epidemiologic Measures of Association Relative risk Odds ratio Attributable risk/population attributable risk percent Standardized mortality ratios

29 Cause - Effect Relationship Cause/risk/exposure Effect/disease/outcome Disease Population People without disease Exposed Not exposed No disease Disease No disease

30 2 x 2 Tables in Epidemiology Used to summarize frequencies of disease and exposure and used for calculation of association Disease Yes No Total Exposure Yes a b a + b No c d c + d Total a + c b + c a + b + c + d

31 2 x 2 Tables in Epidemiology Used to summarize frequencies of disease and exposure and used for calculation of association Disease Exposure Yes No Total Yes (exposed) a b total # exposed No (unexposed) c d total # unexposed Total total # with disease total # with no disease Total Population

32 Relative Risk The ratio of the risk of disease in persons exposed compared to the risk in those unexposed Often, a measure of association between incidence of disease and exposure of interest RR = Incidence rate of disease in exposed Incidence rate of disease in unexposed

33 Disease Exposure Yes No Total Yes a b a + b No c d c + d Total a + c b + c a + b + c + d Relative Risk = a / (a + b) c / (c + d)

34 Example: Relative Risk Develop CHD Do Not Develop CHD Totals Incidence per 1000/yr Smokers Nonsmokers Incidence in smokers = 84/3000 = 28.0 Incidence in non-smokers = 87/5000 = 17.4 Relative risk = 28.0/17.4 = 1.61

35 Interpretation of Relative Risk 1 = No association between exposure & disease incidence rates are identical between groups > 1 = Positive association exposed group has higher incidence than non-exposed group < 1 = Negative association or protective effect non-exposed group has higher incidence example: 0.5 = half as likely to experience disease

36 Interpretation of Relative Risk A relative risk of 1.0 or greater indicates an increased risk A relative risk less than 1.0 indicates a decreased risk

37 Odds Ratio The ratio of the odds of a condition in the exposed compared with the odds of the condition in the unexposed Usually applied to prevalence studies rather than incidence studies OR = odds of disease in exposed odds of disease in unexposed

38 Odds Ratio Disease Exposure Yes No Total Yes a b a + b No c d c + d Total a + c b + c a + b + c + d Odds Ratio = [ a / b ] [ ad ] = [ c / d ] [ bc ]

39 Based on the Odds Ratio formula, what is the Odds Ratio for each disease status in this famous smoking study? Smoking and Carcinoma of the Lung Disease Status Males Lung cancer Number of smokers 647 Number of nonsmokers 2 Males Controls Females Lung cancer Females Controls Doll R. Bradford, Hill A. Smoking and carcinoma of the lung: preliminary report. British Medical Journal 1950, 2:

40 Measures of Potential Impact Reflect the expected contribution of a study factor to the frequency of a disease in a particular population. These measures are useful for predicting the efficacy or effectiveness of therapeutic maneuvers and intervention strategies within a specific population, e.g., vaccine Essentially, potential impact measures are a combination of frequency and association measures

41

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