3-Measures of Disease Frequency

Measures of Disease Frequency
Maia Kajaia, MD, MS

Objectives of Epidemiology
• Determine the extent of the disease in a population
• Identify patterns and trends in disease occurrence
• Identify the causes of the disease
• Evaluate the effectiveness of prevention and treatment activities
The first step in achieving these objectives is measuring how often

the disease arises in a population
Definition of a population
Population - a group of people with a common characteristic such as

place of residence, gender, age, religion, use of hospital services etc.
Types of population:
Fixed (closed) population – membership is based on an event and is
permanent (e.g. Japanese atomic bomb survivors)
Dynamic (open) population – membership is based on a condition
and is transitory (e.g. residents of a city, hospital patients)
3
Definitions of HEALTH and DISEASE
• According to WHO “Health is a state of complete physical, mental and

social well-being and not merely the absence of disease or infirmity”
• Definition of disease is based on combination of physical and

pathological examinations, diagnostic test results and signs and
symptoms
• Case (a person who meets disease definition) is determined by specific

criteria
• Which and how many criteria are used to define a “case” is important
for accurately determining who has the disease
Measuring disease occurrence
• Epidemiologists must always consider three factors when measuring
disease occurrence in a population:
1) Number of people that are affected by the disease
2) The size of population from which the cases of disease arise
3) Length of time that the population is followed
• Failure to consider all three components will give a false impression

about the impact of the disease on a population.
Hypothetical example
• Country A with population 50,000 – 100 new cases of breast cancer

in 1-year period
• Country B with population 5,000 – 75 new cases of breast cancer in

3-year period
• Which country has higher frequency of new breast cancer cases?

Comparing the frequencies of breast cancer in two countries
• For meaningful comparison data must be converted into the same

population size and time period:
For country A:
— if country’s population were 100,000, the disease frequency would
double and become 200 cases/100,000 population/one year;
For country B:
— calculate frequency of breast cancer for the same size population
(5,000) per one year: 75/3=25
— calculate frequency of breast cancer for 100,000 population:
25X20=500 cases/100,000 population/one year
Comparing the frequencies of breast cancer in two countries
Type of data Country A Country B
Number of cases 100 75
Population size 50,000 5,000
Follow-up period 1 year 3 years
Comparable disease 200/100,000/year 500/100,000/year

frequency
Comparing disease frequencies between groups
• Commonly used 100,000 population and 1 year period
• Other population sizes and (such as 1,000 or 10,000) and time

periods (such as 1 month or five years) can be used
• Guiding principle: same population size and time period should be

used for the compared groups;
Types of calculations used to describe and compare
disease frequency
1) Ratio
2) Proportion
3) Rate
RATIO
A fraction in which the numerator is not part of the denominator

(division of two unrelated numbers).
Examples:
Fetal death ratio: fetal deaths/live births.
Fetal deaths are not included among live births.
Sex ratio: males/females (usually expressed as the number of males per

100 females).
Males are not included among females.
PROPORTION
A fraction in which the numerator is part of the denominator.
Range from 0 to 1 or 0% to 100%.
Examples:
Proportion of fetal deaths: fetal deaths/all births
All births include both live births and fetal deaths.
Proportion of black US residents: black residents/all residents

All residents include both black residents and other races)
RATE
A proportion in which change over time is considered.
Example:
200 cases/100,000 population/one year (hypothetical example from
previous slide)
Unfortunately, the term “rate” is often incorrectly used to describe

ratios and proportions.
Proportions vs Rates
• Proportions – concerned with (disease) states

• Useful for assessing health status of population
• Planning health care services
• Quality of care
• Screening for asymptomatic disease
• Rates – concerned with (disease) events

• Useful for assessing causation
Measures of disease frequency
• Incidence (measures the occurrence of new disease)
• Prevalence (measures existence of current disease)

Incidence
• Incidence is the occurrence of new cases of disease that

develop in population over a specified time period.
Two types:
1) Cumulative incidence
2) Incidence rate
Cumulative incidence
Number of new cases of disease occurring

over a specified period of time in a population
at risk at the beginning of the interval.
EXAMPLE OF CUMULATIVE INCIDENCE
If we count all new cases of influenza occurring in CIU

students from September 1, 2018 - August 31, 2019, and we
take as the denominator all students enrolled in September 1,
2018, we would be describing the cumulative incidence rate of
influenza.
Incidence Proportion/Cumulative incidence/Attack rate
0 0.5
Diabetes
Adult Population Year 2014
Adult Population
2010 (no diabetes)
Incidence proportion= 0.5

Incidence rate impossible to calculate (once diseased, stop being “at risk”).
Incidence rate
Number of new cases of disease occurring over a

specified period of time in a population at risk
throughout the interval.
• Incidence rate requires us to add up the period of time each
individual was present in the population, and was at risk of
becoming a new case of disease
• Incidence rate characteristically uses as the denominator

person-years at risk (time period can be person-months, days, or
even hours, depending on the disease process being studied)
EXAMPLE OF INCIDENCE RATE
• The numerator does not differ between the two types of incidence: we count
all new cases of influenza occurring in CIU students from September 1, 2018 -
August 31, 2019;
• However, the denominator differs in incidence rate from cumulative incidence

because it takes account of (in the example):
Students who left school during the year
Students who died
Students who had influenza once and will not have it again the same season
Students who entered school later in the year
Get disease
Incidence Rate
14
Years until diabetes 12
10
8
6
4 X
2
0
1 2 3 4 5
Individual
Death
Prevalence
• Prevalence is the proportion of the total population that is diseased
Two types:
1) Point prevalence
2) Period prevalence
POINT PREVALENCE
Proportion of population that is diseases at a single point in time
(single snapshot of a population).
Diabetes
Adult Population
• The proportion with disease (at given point in time)

PERIOD PREVALENCE
Proportion of population that is diseased during a specified
period of time (derived from series of snapshots).
For example:
• annual prevalence rate
• lifetime prevalence rate
(When the type of prevalence rate is not specified it is usually

point prevalence, or its closest practical approximation)
Comparison
Prevalence Incidence
• One point in time; easy to measure • Involves time; difficult to measure
• Proportion or % • Measured as either rate or
• Affected by many factors apart from proportion
those causing disease. • Less affected by other influences.
• Numerator: count of people with • Numerator: count of people who
disease develop disease during follow-up
• Denominator: count of total • Denominator:
population at risk – (prop.) People at risk and disease free
• No time component – (rate) Person-time at risk.
Summary
• Prevalence (among population, proportion with historic
diagnosis of disease)
• Incidence proportion (disease free, follow, proportion that

develop disease in defined period)
• Incidence rate (disease free, follow, number of cases that

develop disease divided by time at risk)
USES OF INCIDENCE AND PREVALENCE
Incidence is generally used for acutely acquired diseases, prevalence

is used for more permanent states, conditions or attributes of ill-
health.
Incidence is more important when thinking of etiology of the

disorder, prevalence when thinking of societal burden of the
disorder including the costs and resources consumed as a result of
the disorder.
Incidence always requires a duration, prevalence may or may not.

USES OF INCIDENCE AND PREVALENCE
In incidence, the unit of analysis is the event, in prevalence, it is

the person. Thus incidence may exceed 100% (e.g. annual
incidence of colds) unless a convention is adopted to count only
first episodes of an illness that can occur more than once.
Prevalence can never exceed 100%.
Incidence generally requires an initial disease-free interval before

counting starts, because incidence is measured only in those at-
risk of disease.
USES OF INCIDENCE RATE AND CUMULATIVE INCIDENCE
• Incidence density gives the best estimate of the true risk of

acquiring disease at any moment in time.
• Cumulative incidence gives the best estimate of how many

people will eventually get the disease in an enumerated
population.
RELATIONSHIP BETWEEN INCIDENCE AND PREVALENCE
In a STEADY STATE (i.e. if incidence is not changing, and the

population is stable)
Prevalence rate = incidence rate times the duration of disease
(P = I x D)
Thank you !!!

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Measures of Disease Frequency

Maia Kajaia, MD, MS

• Determine the extent of the disease in a population

• Identify patterns and trends in disease occurrence

• Identify the causes of the disease

• Evaluate the effectiveness of prevention and treatment activities

The first step in achieving these objectives is measuring how often

Population - a group of people with a common characteristic such as

• According to WHO “Health is a state of complete physical, mental and

• Definition of disease is based on combination of physical and

• Case (a person who meets disease definition) is determined by specific

• Failure to consider all three components will give a false impression

• Country A with population 50,000 – 100 new cases of breast cancer

• Country B with population 5,000 – 75 new cases of breast cancer in

• Which country has higher frequency of new breast cancer cases?

• For meaningful comparison data must be converted into the same

Type of data Country A Country B

Number of cases 100 75

Population size 50,000 5,000

Follow-up period 1 year 3 years

Comparable disease 200/100,000/year 500/100,000/year

• Commonly used 100,000 population and 1 year period

• Other population sizes and (such as 1,000 or 10,000) and time

• Guiding principle: same population size and time period should be

A fraction in which the numerator is not part of the denominator

Sex ratio: males/females (usually expressed as the number of males per

Proportion of black US residents: black residents/all residents

A proportion in which change over time is considered.

Unfortunately, the term “rate” is often incorrectly used to describe

• Proportions – concerned with (disease) states

• Rates – concerned with (disease) events

• Incidence (measures the occurrence of new disease)

• Prevalence (measures existence of current disease)

• Incidence is the occurrence of new cases of disease that

Number of new cases of disease occurring

If we count all new cases of influenza occurring in CIU

Incidence proportion= 0.5

Number of new cases of disease occurring over a

• Incidence rate characteristically uses as the denominator

• However, the denominator differs in incidence rate from cumulative incidence

• Prevalence is the proportion of the total population that is diseased

• The proportion with disease (at given point in time)

(When the type of prevalence rate is not specified it is usually

• Incidence proportion (disease free, follow, proportion that

• Incidence rate (disease free, follow, number of cases that

Incidence is generally used for acutely acquired diseases, prevalence

Incidence is more important when thinking of etiology of the

Incidence always requires a duration, prevalence may or may not.

In incidence, the unit of analysis is the event, in prevalence, it is

Prevalence can never exceed 100%.

Incidence generally requires an initial disease-free interval before

• Incidence density gives the best estimate of the true risk of

• Cumulative incidence gives the best estimate of how many

In a STEADY STATE (i.e. if incidence is not changing, and the

Prevalence rate = incidence rate times the duration of disease

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