Measures of Disease Frequency

dr. Ratna Sari Wijaya, M.Biomed, PhD

Introduction
• The outcomes of epidemiologic research have been traditionally defined in terms of diseases

• In addition to diseases, epidemiologic research also study health outcomes in population

• Health outcomes is a broad term, including; diseases, conditions, disorders, symptoms,

behaviors, risk factors, and injuries

• Measures of diseases frequency ↔ measures of health outcomes frequency

• Measuring the frequency of diseases (health outcomes) and monitor the changes over time
in population are important steps for;
• Discovering the potential causes of a diseases
• Determining the effective methods for prevention and care
Introduction

• Quantifying disease frequency is usually done using

• Prevalence
• Incidence

• Prevalence
• Point prevalence
• Period prevalence
• Cumulative prevalence

• Incidence
• Incidence risk/ cumulative incidence/ incidence proportion
• Incidence rate/ Incidence density/ Hazard rate/person-time incidence
• Incidence odds
Prevalence

• The frequency of existing cases of a disease or health outcome in a defined population at a

certain time or period

• Use existing cases of the health outcome

• Individuals with health outcome of interest, regardless of when diagnosed

• The prevalence is often useful as it reflects the burden of a disease in a certain population,
relatively easy to estimate, and implies a cross-sectional study design
Prevalence
• Calculation
NumeratorNumber of people with the disease or condition at a specified time
Denominator Number of people in the population at risk at the specified time

• Important to think who should be in the denominator of your calculation for measuring of
disease frequency
• Ideally the denominator consists of the people who are potentially susceptible to the disease or health come that
being studied  population at risk
Prevalence
• Example of prevalence
• During flu season, there are 10 sick medical students and 40 healthy medical students
taking a basic anatomy course. What is the prevalence of the flu among these students ?
• Prevalence = (10/50) x 100 = 20%

• Depending on how “time” is defined, there are three kinds of prevalence measurements
• Point prevalence
• Cases at a given point in time
• Period prevalence
• Cases during a given period (interval time)
• Cumulative (lifetime) prevalence
• Cases at any time in the past up to the present time
Incidence

• The incidence represent the

number of new cases of disease
within a certain period

• Can be expressed as a risk or

rate

• Incidence is best understood in

the context of prospective
(cohort) studies
Incidence risk
• Calculation
Number of people who get the disease during a specified period
Number of people free of the disease in the population at risk at beginning of the period

• Incidence risk measures the number of new cases of the disease or health
outcome that develop among people in the population at risk, over a
specified time period

• Incidence risk refers to the probability that a disease or health outcome will
occur

• Risk can be expressed as a proportion

Incidence risk
• Incidence risk example
• The population statistic of Tangerang district in 2001 revealed that there were 100 women aged 20-39
years who where sex workers. Based on the health record among those women, 20 were HIV positive
during 2002-2005. What is the incidence risk of HIV positive among those women during period of 4
years?
• Incidence risk = 20/100 = 0.2 or 20%

• When calculating a risk, a few assumptions need to be made

• A specified time period
• Closed study population
• Does not have a disease at start of study
Incidence rate
• Calculation
Number of people who get the disease (new cases)
Time each person was observed (person-time), totaled for all person

• Incidence rate measures how quickly the health outcome is occurring in a

population of interest

• Benefit of measuring rate; flexible, exact, capture reality of changing

population

• Person-time is defined as the sum of time that each person remains at risk for
the disease or health outcome and under study observation (can be expressed
as person-years, person-months, person-days)
Incidence rate
• Person-time can be stop to be calculated; death, unable to follow-up, person
develop the disease or health outcome during the study, leaving the study
Years 1 2 3 4 5 6 7 8 Time at risk
Subject 1 D 4
Subject 2 3
Subject 3 3 X
Subject 4 8
Subject 5 6 L
X; death, D; disease, L; loss to follow-up

Total person-time = 4+3+3+8+6 = 24 person-years

Rate over 8 years = 1/24 = 0.041 or 4.1 cases per 100 person-years
Odds
• Odds of an event; the ratio of
probability that an event will occur,
to the probability that the event will
not occur

• Benefit of measuring rate; easy to

calculate and interpret, can be used
for certain design study (case-
control study)
Measures of association

• Compare measures of disease occurrence in two different groups (exposed

vs unexposed)

• Comparison can be made by

• Division (ratio effect)
• Risk ratio (RR)
• Odds ratio (OR)

• Subtraction (difference effect)

• Risk difference (RD)
Measures of association

• Two by two tables (contingency tables)

Disease (+) Disease (-)
Exposed a b RR : 1  no association
c d RR <1  risk in exposed is lower than non-
Non-exposed exposed, possibly protective
RR >1  risk in exposed is higher than non-
exposed, possibly causal

Risk exp = a/(a+b)

RD : 0  no association
Risk non-exp = c/(c+d) RD <0  risk in exposed is lower than non-
exposed, possibly protective
Risk ratio (RR) = Risk exp/ Risk non-exp RD >0  risk in exposed is higher than non-
exposed, possibly causal
Risk difference (RD) = Risk exp – Risk non-exp
Measures of association

• Example of risk ratio and risk difference calculation and interpretation

The study investigate the association between texting while driving with traffic
accident between January-December 2020
Here is data on 2 x 2 table Interpretation
Risk exp  Among those who texted while driving, 9.09%
Traffic accident (+) Traffic accident (-) reported a traffic accident in a 1-year time period

Texting (+) a = 30 b = 300 Risk non-exp  Among those who did not text while driving, 1.1%
Texting (-) c=5 d = 450 reported a traffic accident in a 1-year time period

Risk ratio  Those who texted while driving were approximately

Risk exp = 30/330 = 9.09% 8 times as likely to have traffic accident compared with those who
Risk non-exp = 5/455 = 1.10% did not text while driving over a 1-year time period
Risk ratio (RR) = 9.09/1.10 = 8.27 Risk difference  Among those who texted while driving, the risk
Risk difference (RD) = 9.09%-1.1% = 7.99% of traffic accident was 7.99% higher than those who did not text
while driving over a 1-year time period
Measures of association
• Odds ratio (OR)  case control study

Case Control
Exposed a b
Non-exposed c d

OR = odds of being exposed in case/odds of being exposed in controls = (a/c) : (b/d)  (a*d) / (b*c)
In the study, 186 of the 263 adolescents previously judged as SB NS
having experienced a suicidal behaviour requiring immediate
psychiatric consultation did not exhibit suicidal behaviour Depression (+) 45 86
(non-suicidal, NS) at six months follow-up. Of this group, 86 32 100
young people had been assessed as having depression at Depression (-)
baseline. Of the 77 young people with persistent suicidal
behaviour at follow-up (suicidal behaviour, SB), 45 had been
assessed as having depression at baseline.

OR : 1  no association OR  (45 x 100) : (32 x 86)  1.63

OR <1  negative association Interpretation  Adolescent with baseline depression diagnosis
OR >1  positive association had 1.63 times as likely to have persistent suicidal behaviour
compared to adolescent with no baseline depression diagnosis
Measures of precision (Confidence interval/CI)

• CI  Statistical construct that provide information regarding the range in

which true value lies with a certain degree of probability

• CI  Is used to estimate the precision of the risk ratio, odds ratio, or other
measurement result of association

• A large CI  low level of precision vs a small CI  higher level of precision

Measures of significance (p-value)
• The "p" value is an expression of the probability that the difference
between the observed value and the null value has occurred by "chance",
or more precisely, has occurred simply because of sampling variability

• The smaller the "p" value, the less likely the probability that sampling
variability accounts for the difference.

• Typically, a "p" value less than 0.05, is used as the decision point, meaning
that there is less than a 5% probability that the difference between the
observed risk ratio, rate ratio, or odds ratio is due to sampling variability
References

• Szklo M, 2019. Epidemiology beyond the basics 4th edition. Jones &
Bartlett learning

• Bonita R, 2006. Basic epidemiology 2nd edition. World Health

Organization