1. Measurement Measuring disease and death frequency FETP India

2. Competency to be gained from this lecture Calculate incidence, prevalence, mortality and case fatality

3. Key areas Prevalence Incidence Relation between prevalence and incidence Mortality

4. Population at risk Portion of a population that is susceptible to a disease Can be defined on the basis of demographic or environmental factors Prevalence

5. Population at risk: Examples Population at risk of developing carcinoma of the cervix:  Female population  Age > 30 and < 70 years Population at risk of hepatitis B  Those individuals anti-HBc negative Prevalence

6. Prevalence – (P) Number of existing cases (old and new) in a defined population at a specified point of time # people with disease at a specified time P = -------------------------------------------------- x 10n Population at risk at the specified time In some studies the total population is used as an approximation if data on population at risk is not available Prevalence

7. Point prevalence Measures the frequency of disease at a given point in time Applies when the data has been collected at one point in time P = C / N  C = # of observed cases at time ‘t’  N = Population size at time ‘t’ Prevalence

8. Example of point prevalence 150 children in a school Screening for refractory errors at time “t” 15 children require glasses Prevalence of refractory errors  15 / 150 = 10% Prevalence

9. Period prevalence - (PP) Measures the frequency of disease over some time Applies when the data has been collected over a period of time PP = C + I / N  C = # of prevalent cases at the beginning of the time period  I = # of incident cases that develop during the period  N = size of the population for this same time period Prevalence

10. Exercise Scenario  Population of 150 persons  Follow-up for one year  25 had a disease of interest at the beginning  Another 15 new cases developed during the year Calculate:  Point prevalence at the start of the period  Period prevalence for the year P = C/N = 25 /150 = 0.17 (17 %) PP = (C+I)/N = (25+15)/150 = 0.27 (27 %) Prevalence

11. Factors influencing prevalence Number of new cases Duration of the illness  If the disease is short, the prevalence is reduced The prevalence of sudden infant death = 0  If the disease is long, the prevalence is increased Rare-lifelong disease can accumulate to build up a large prevalence Prevalence

12. Causes of increase and decrease of prevalence Increase Long duration  Low cure rate  Low case fatality Increase in new cases Immigration of patients Improved detection Emigration of healthy people Decrease Shorter duration  High cure rate  High case fatality Decrease in new cases Emigration of patients Improved cure rate Immigration of healthy people Conclusion: Changes in prevalence may have many causes and are difficult to interpret Prevalence

13. Uses of prevalence data Assessing health care needs Planning health services Measure occurrence of conditions with gradual onset Study chronic diseases Prevalence

14. Incidence – (I) Number of new cases in a given period in a specified population  Time, (i.e., day, month, year) must be specified Measures the rapidity with which new cases are occurring in a population Can be expressed:  In absolute numbers  In terms of cumulated incidence  In terms of incidence density Incidence

15. Cumulated incidence - (CI) # of new cases CI = -------------------------------------------------- x 10n Population at risk at the beginning Also known as:  Attack rate Assumes that the entire population at risk at the beginning was followed-up for the time period of observation Incidence

16. Cumulated incidence calculation over 7 years of observation Development of illness ? ? ? ? Person included: 8 Lost to follow up: 4 Illness: 1 Cumulated incidence: 25% 7 years Incidence

17. Risk Probability that an individual will experience a health status change over a specified follow–up period This assumes that the individual does not:  Have disease at the beginning  Die from other causes during follow-up Corresponds to cumulated incidence Incidence

18. Incidence density - (ID) # of new cases ID = -------------------------------------------------- x 10n Total person-time of observation Also known as:  Incidence rate Reflects more exactly the person-time observed Incidence

19. Incidence density calculation with annual observations during 7 years One yearDevelopment of illnessCensored Person-year at risk: 41 Illness: 2 Incidence density: 4.9 / person -year Incidence

20. Uses of incidence data Describe trends in diseases Evaluate impact of primary prevention programmes Incidence

21. Prevalence Incidence Death Cure New cases The dynamics of incidence and prevalence Incidence and prevalence

22. The relation between prevalence and incidence Prevalence depends on  Incidence (I)  Duration of the disease (D) P = I x D Change in prevalence from one time period to another may be the result of changes in incidence rates, changes in the duration of disease, or both Incidence and prevalence

23. Patterns of incidence and prevalence High prevalence and low incidence  e.g., Diabetes Mellitus Low prevalence and high incidence  e.g., Common cold Incidence and prevalence

24. Evolution of HIV prevalence in a country scaling up public health efforts Increase in prevention  Reduction in incidence (Difficult to measure) Increase in care and support (treatment)  Increase in disease duration (reduced mortality)  Increase in prevalence (easier to measure) Incidence measures the impact of prevention efforts Prevalence may be used to plan care and support The immediate consequence of the plan may be an increased prevalence Incidence and prevalence

25. Crude mortality rate - (CMR) # deaths in a specified period CMR = ------------------------------------------------ x 10n Average total population Does not take into account factors such as age, sex, race, socio-economic status, etc. Provides information on trends in a population’s health status Deaths

26. Disease-specific mortality rate - (SMR) # deaths from a disease in a specified period SMR = ------------------------------------------------ x 10n Average total population Reflects the impact of a disease on a population in terms of death Should not be confused with case fatality Deaths

27. Case fatality Places in relation the number of deaths from a disease to the number of cases Reflects severity Can be expressed as:  Proportion  Ratio  Not as rate (although often referred to as case fatality rate) Deaths

28. Case fatality proportion # deaths among the cases identified CF = ------------------------------------------------ x 10n # of cases Applies to a situation where follow-up information is available individually for all case-patients The numerator is a part of the denominator Deaths

29. Case fatality ratio # reported deaths from a disease CFR = ------------------------------------------------ x 10n # of reported cases from the disease Used in surveillance when no specific information is available on follow-up of individual patients The deaths in the numerator may not correspond to the cases in the denominator Deaths

30. Take-home messages Prevalence is a static measure taken at a point in time Incidence is a dynamic measure taken over a certain time Mortality is calculated using population denominators to reflect burden while case fatality is calculated using cases as denominators to reflect severity