Measures of Disease

Frequency
(UKURAN FREKUENSI
PENYAKIT)

dr Hj Arulita Ika Fibriana M.Kes

(Epid)
 PENDAHULUAN
• Definisi Epidemiologi :
“ the study of the distribution and determinants of
health related states or events in specified
populations and the application of this study to
control of health problems”

(Studi yg mempelajari distribusi & determinan

penyakit dan masalah kesehatan pd populasi 
penerapannya utk mengendalikan masalah kesehatan
tsb)
Epidemiology is a Science of Rates

• death rates
• disability rates
• hospitalization rates
• incidence rates
• prevalence rates
 Approaches Towards Monitoring
Disease and Injury

Death Certificates
Population Surveys
Surveillance
Registries
Screening
 Numbers, proportions,
ratios and rates
• Epidemiology needs :
(1)the number and characteristics of disease cases,
(2)the number and characteristics of people with risk
factors
(3) of the population from which the above people derive.
• Numbers of cases, or people with the risk factors
comprise the NUMERATOR (the top half of the
fraction) - the population from which they come is the
DENOMINATOR (the bottom part in of factions)
• The fraction, numerator divided by the denominator, is
usually called the rate in epidemiology
FRACTIONS USED IN DESCRIBING
DISEASE FREQUENCY
RATIO
•A ratio is one number in relation to another.
A fraction in which the numerator is not
part of the denominator.
e.g. Fetal death ratio:
Fetal deaths/live births.
Fetal deaths are not included among live
births, by definition.
PROPORTION

A fraction in which the numerator is part of the

denominator.
e.g. Fetal death rate: Fetal deaths/all births
All births includes both live births and fetal
deaths.

– Synonyms for proportions are: a risk and, (if

expressed per 100) a percentage.
– Most fractions in epidemiology are
proportions.
RATE 
Ideally, a proportion in which
change over time is considered, but
in practice, often used
interchangeably with proportion,
without reference to time, (as I did
previously for fetal death rate).
 Rates

• Rates are the basic tool of

epidemiologic practice

• Why are rates important?

• because they provide more complete
information to describe or assess the impact of
disease in a community or population
 Why are rates useful?

• Can help to identify groups with an

elevated risk of disease

– can target interventions to these

groups
– these groups can be studied to identify
risk factors
• Rate: a measure of the occurrence of a
health event in a population group at a
specified time period
Numerator Number of events in time
: period

denominator Number at risk for

the event
 Three common types of rates

• Crude rates
• Specific rates
• Adjusted rates
 Three common types of rates
• Crude rates
– consider the entire population
• Specific rates
– consider differences among subgroups of the
population
• Adjusted rates
– adjust for differences in population
composition
• Crude rates
• Crude death rate = number of deaths
in time period
total population
• Specific rates
• Age-specific = number of deaths in age
group in time period
death rate population in age group
 Adjusted Rates
• Use statistical procedures to adjust for
differences in characteristics between
populations
• Age is the most frequent factor adjusted
for because age is related to both death
and disease
• Adjusted rates do not describe actual
occurrence, but are hypothetical given
certain assumptions
 Morbidity

• any departure from health

• i.e. the extent of illness, injury or
disability in a defined population
• morbidity rates are used as indicators of
health
• in epidemiology, the main measures of
morbidity are incidence and prevalence
MEASURES OF DISEASE
FREQUENCY
PREVALENCE RATE

Divided into two types:

1. Point prevalence rate
2. Period prevalence rate
 Prevalence
• Prevalence: is one of the major
measure of disease in the population
• information available from surveys,
registries, or investigations
 Prevalence rate

• Count of cases (new and old) at a point in time

in a population size defined by characteristics
(age, sex, etc) and place
• Obtained from cross-sectional studies or
disease registers
• The formula is:
• All cases
total population
• Prevalence Rate = Number of existing cases
of disease in population
in time period
x 1000
Total Population
in same time period
POINT PREVALENCE RATE

Proportion of individuals in a
specified population at risk who
have the disease of interest at a
given point in time.
 Point Prevalence Rate
= Number of cases of
disease at a given
point in time

Estimated population
at the same point in time
PERIOD PREVALENCE RATE
Proportion of individuals in a specified
population at risk who have the disease of
interest over a specified period of time.
For example:
• annual prevalence rate
• lifetime prevalence rate.
(When the type of prevalence rate is not specified it is
usually point prevalence, or its closest practical
approximation)
 Several factors may affect
prevalence
• Incidence
• Duration of disease
• Disease treatments
• Disease reported
Figure 7.4

Incident cases

Prevalent cases

Deaths, emigrations and recovery

Figure 7.7

Births
Recoveries
Population reservoir Immigration

Incident cases
Emigrant cases,
Prevalent cases unmeasured cases
occurring abroad,
and deaths
Emigrant and non-
Recoveries measured cases,
deaths
What is the point prevalence on
April 1?
What is the point prevalence on April 1?

7 / 18
INCIDENCE RATE

Like prevalence, divided into two

types:
1. Cumulative incidence
2. Incidence density/ incidence
rate
 Incidence Rate
• The numerator has to come from the
population at risk for developing
disease
• The denominator may change over
time as people develop disease
• The denominator does not include
persons with the disease
 Incidence Rate

However, in practice
•in large studies, the
denominator is often the mid-
year population
•in small studies, the
denominator does not include
persons with the disease
1. 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 MSU undergraduates
from September 1, 1997 - August 31,
1998, and we take as the
denominator all undergraduates
enrolled in September 1, 1997, we
would be describing the cumulative
incidence rate of influenza.
What is the cumulative incidence
from
October 1, 1990 to Sep 30, 1991?
What is the cumulative incidence from
October 1, 1990 to Sep 30, 1991?

4 / 14
EXAMPLES: Calculating Incidence Proportion
(Risk)

Example A: In the study of diabetics, 100 of

the 189 diabetic men died during the 13-year
follow-up period.
Calculate the risk of death for these men.
Numerator = 100 deaths among the diabetic men
Denominator = 189 diabetic men
10n = 102 = 100
Risk = (100 / 189) x 100 = 52.9%
Example B: In an outbreak of gastroenteritis
among attendees of a corporate picnic, 99 persons
ate potato salad, 30 of whom developed
gastroenteritis. Calculate the risk of illness among
persons who ate potato salad.

Numerator = 30 persons who ate potato salad and

developed gastroenteritis

Denominator = 99 persons who ate potato salad

10n = 102 = 100
Risk = “Food-specific attack rate” = (30 / 99) x 100 =
0.303 x 100 = 30.3%
 2. Incidence density:

Number of new cases of disease

occurring over a specified period
of time in a population at risk
throughout the interval.
The numerator does not differ between the
two types of incidence
However, the denominator can differ in
incidence density from cumulative
incidence because it takes account of
(in the example):
•Students who left school during the year
•Students who died
•Students who had influenza once and will not
have it again the same season
•Students who entered school later in the year
Incidence density requires us to add up
the period of time each individual was
present in the population, and was at risk
of becoming a new case of disease.
Incidence density characteristically uses
as the denominator person-time at risk.
(Time period can be person-years,
months, days, or even hours, depending
on the disease process being studied.)
 Insidence density (ID)
= Incidence rate = Laju Insidensi

• Adalah ukuran yang menunjukkan kecepatan

kejadian (baru) penyakit pada populasi

RUMUS
Jumlah kasus baru
ID =

Person Time
 PERSON TIME
• Adalah jumlah orang dalam risiko
dikalikan lamanya masing-masing orang
dalam risiko

Satuan : orang-hari (person day)

orang-minggu (person week)
orang-jam (person hours)
 Contoh Soal

Pengamatan pada 6 orang selama 7

tahun mengenai penyakit kanker
pada orang yang bebas kanker
1
2
3

4
5
6

2 3 4 6 7
Waktu pengamatan (tahun)
 Berapakah IC & ID?
IC = 3
= 0.5
6
ID = 3 = 0.1
29
 Kesimpulan

• IC= 0.5 artinya risiko terkena kanker

selama 7 tahun terpapar adalah 50 persen
• kecepatan insidensi (ID) 0,1 artinya 10
orang terkena kanker dari 100 orang yang
terpapar selama setahun
The mortality rate is a type of
incidence rate. It is the most
widely used public health
measure, but it has limitations.
 USES OF INCIDENCE AND
PREVALENCE
1. Incidence is generally used for acutely
acquired diseases, prevalence is used for
more permanent states, conditions or
attributes of ill-health.
2. Incidence is more important when thinking
of etiology of the disorder, prevalence when
thinking of societal burden of the disorder
including the costs and resources
consumed as a result of the disorder.

3. Incidence always requires a duration,

prevalence may or may not.
 Difference between incidence
rates and prevalence rates
Incidence Prevalence
• Numerator: New • Numerator: All cases
cases occurring present (new and
during a given time existing) during a
period given time period
• Denominator:
• Denominator: Number in
Number at risk of population
developing disease
4. In incidence, the unit of analysis is the
event, in prevalence, it is the person.
Thus incidence may exceed 100% (e.g.
annual incidence of colds) unless a
convention is adopted to count only first
episodes of an illness that can occur
more than once.
5. Prevalence can never exceed 100%.
6. Incidence generally requires an initial
disease-free interval before counting
starts, because incidence is measured
only in those at-risk of disease.
Uses of Prevalence and Incidence
• Prevalence is a more relevant measure
when assessing the impact of a
problem within a community and to
assess the subsequent needs.
• Prevalence should be used with
caution in evaluating associations
between variables.
Uses of Prevalence and Incidence
• In studies of prevalence, it is very difficult
to distinguish :
 Effects of factors affecting the
occurrence of disease from the effects of
factors that increase survival (or duration
of the problem).
• This difficulty often leads to incorrect
conclusions.
• Prevalence rather than incidence is
often measured for chronic diseases
such as diabetes or osteoarthritis which
have long duration and dates of onset
that are difficult to pinpoint.
 USES OF INCIDENCE DENSITY 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)
Prevalence Incidence rate x average
= duration of disease
rate

Incidence Prevalence

Longer duration Prevalence

Better treatment Prevalence

 Frequently Used Measures of
Morbidity
Measure Numerator Denominator
Cummulative Number of new cases Population at start of
Incidence of disease during time interval
(or attack rate or risk) specified time
interval

Incidence rate (or Number of new cases Summed person-years

person-time rate) of disease during of observation or
specified time average population
interval during time interval
 Frequently Used Measures of
Morbidity
Measure Numerator Denominator
Secondary attack rate Number of new cases Total number of
among contacts contacts

Point prevalence Number of current Population at the same

cases (new and specified point in
preexisting) at a time
specified point in time

Period prevalence Number of current Average or mid-

cases (new and interval population
preexisting) over a