Epidemiologic measures

Helmy Hazmi, MD (UNIMAS), MComMed (Epid & Biostats)(USM)

 Learning objectives
In the end of the lecture, students will be able to:
1. Frequency Measures (rates, ratio and proportion)
2. Morbidity Frequency Measures (incidence, prevalence)
3. Crude, specific and adjusted rates
4. Measures of association (RR, OR, NNT, NH, HR)
5. Selected indices of health
6. Explain the sources of errors.
 Why do we need to know the numbers?
• Allows assessment of the severity of disease / health related events – indicators
of heath status in a population.
• Monitoring of diseases / health related event – surveillance.
• Monitor progress of health programs.
• Plan for correct data collection method.
• Allow correct source of data collection.
• The need to communicate numbers to another person who needs to know.
 Concept
Improvement of survival – better health care, aging, better nutrition

Measures of mortality Measures of morbidity

The measures of death. It The measures of the number

includes mortality rate, case illness. Includes incidence and
fatality rate and proportional prevalence. Common source
mortality rate / ratio. include surveillance and
sample surveys
Measuring diseases 1

Ratios, Proportion,
Rates
 Ratios
• The value obtained by dividing one quantity over the other.
• Expresses the relation in size between 2 different quantities.
• Expressed as X : Y or x/y X k.
• The ratio of male to female in district x is 1,791,000 : 1,703,000 or
1.052 to 1.
 Proportion
• Specific type of ratio. No time element.
• Numerator included in the denominator.
• Resultant value is expressed as percentage.
• Eg:
• prevalence of disease X among pregnant mothers.
• Proportion of male births:
𝑀𝑎𝑙𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 179 𝑋 104
• = = 51.3%
𝑚𝑎𝑙𝑒+𝑓𝑒𝑚𝑎𝑙𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 179+170 𝑋 104
 Rates
• Special form of proportion.
• Expresses probability of disease risk in a defined population and time.
• Formula:
𝑁𝑜. 𝑜𝑓 𝑒𝑣𝑒𝑛𝑡𝑠 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑝𝑒𝑟𝑖𝑜𝑑
• xk
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑜𝑓 𝑡ℎ𝑒𝑠𝑒 𝑒𝑣𝑒𝑛𝑡𝑠 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑝𝑒𝑟𝑖𝑜𝑑

• Eg: rate of cancer death among KCH residents in 2018.

𝑑𝑒𝑎𝑡ℎ 𝑓𝑟𝑜𝑚 𝑐𝑎𝑛𝑐𝑒𝑟 𝑎𝑚𝑜𝑛𝑔 𝐾𝑢𝑐ℎ𝑖𝑛𝑔 𝑟𝑒𝑠𝑖𝑑𝑒𝑛𝑡𝑠 𝑖𝑛 2018
• x 100,000 = 186.3 per 100,000 population.
𝐾𝑢𝑐ℎ𝑖𝑛𝑔 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑖𝑛 2018
 Rates: Natality rate (population dynamics)
Although in epidemiology, we are concerned with morbidity and mortality
rates, we should also not forget natality rates. It is used by demographers for
population projection.
𝑁𝑜 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑓𝑜𝑟 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑡𝑖𝑚𝑒 (𝑦𝑒𝑎𝑟)
Crude birth rates = x 1000
𝐸𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑚𝑖𝑑 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛

𝑁𝑜 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ 𝑓𝑜𝑟 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑡𝑖𝑚𝑒 (𝑦𝑒𝑎𝑟)

General fertility rate = x 1000
𝐸𝑠𝑡 𝑚𝑖𝑑 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 15 −44 𝑦𝑒𝑎𝑟𝑠 𝑜𝑙𝑑

𝑁𝑜 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ 𝑓𝑜𝑟 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑡𝑖𝑚𝑒 (𝑦𝑒𝑎𝑟)

Total fertility rate = x 1000
𝐸𝑠𝑡 𝑚𝑖𝑑 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 15 −49 𝑦𝑒𝑎𝑟𝑠 𝑜𝑙𝑑
Incidence and Prevalence
Measuring diseases 2
Measures of disease frequency
 Incidence
Incidence is a measure of the number of new cases of a disease or other health outcome that develop in
a population of individuals at risk, during a specified time-period.
Risk (Cumulative Incidence) Incidence (aka Incidence Rate)
Is related to a more precise measure of the
Related to the population at risk at the beginning
population at risk during the study period and is
of a study period
measured in person time units
Incidence Risk = Incidence rate =
Number of new cases of disease in a specified period of time Number of new cases of disease in a specified period of time
number of disease free persons at the beginning of that time total person − time at risk during follow up period
Expressed as a percentage (or, if small, as per 1000 Expressed as person-years at risk
persons).
e.g. The overall stroke
e.g. incidence risk of stroke is 2.3 per 1000 incidence rate was 30.2 per 100 000 person-years
population or 0.0023% of observation
Also known as cumulative incidence because it
refers to the occurrence of risk events, such as Also known as Incidence Rate
disease or death in a group studied over time

Numerator is the number of person developing the Numerator is the number of person developing the
disease or event of interest within the time period disease or event of interest within the time period

Denominator = sum of the length of time they

Denominator = number of disease free people at
were followed up in the study or the total time for
the beginning of that time
each followed up subject.

Assumption: the entire population at risk at the

More accurate estimate of the rate of disease
beginning of the study period has been followed
development in a dynamic population and a very
for the specified time for the development of the
long follow up time.
outcome under investigation.
Incidence
The number of new cases of disease that occur during a specified
period of time in a population at risk of developing the disease.

𝑁𝑜 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑠 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛

𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒
𝑁𝑜 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑜𝑓 𝑑𝑒𝑣𝑒𝑙𝑜𝑝𝑖𝑛𝑔 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 x 1000
𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑎𝑡 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒
Incidence rate
Also called incidence density.

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑

ID =
𝑡𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑠𝑜𝑛 𝑡𝑖𝑚𝑒 𝑜𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛

Valid under these conditions:

The risk of disease or death is constant throughout the entire period of being followed up. Rapidly
fatal disease will artificially increase the rate.
Long latency can go either way – artificially reducing the ID (contraceptive failures study) or
increasing it (after environmental hazards exposure)
The rate of disease or death among those lost to follow up must be the same as individuals still under
observation.
Incidence rate
How person years is calculated:
Person Years of follow up Outcome
A 0.5 Drop out
B 2 Diseased
C 1 Diseased
D 3 Died in an accident
E 5 No disease
Total person years 11.5

2
Incidence Density: 11.5 x 1000 = 170 per 1000 person years = 1700 per 10000 person years
Incidence rate
Example: Women Health Study (WHS)
37 105 women contributed to 276 453 person years of follow up.
During the follow up, 1085 women developed breast cancer. Therefore
the incidence density is

1085
= 0.00392 = 392 / 100 000 person years
276453
 Incidence: Some considerations
• Knowledge of the health status of the study population
• Time of onset
• Proper definition of disease onset or be considered as a case.
• Numerator
• Number of persons vs number of conditions
• Number of people who had URTI (regardless of times) vs number of URTIs
• Denominator.
• Midyear population
• Exclude those who have disease or not susceptible because of immunization.
• Large vs Small population – consider attack rate.
• Period of observation.
• Definite period of time.
• Long enough, appropriate of the condition. Bracket years may be used.
 Prevalence
𝑁𝑜 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑠 𝑝𝑟𝑒𝑠𝑒𝑛𝑡 𝑖𝑛 𝑎 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑡𝑖𝑚𝑒
𝑁𝑜 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑛 𝑎 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 x 1000
𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑎𝑡 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒

Characteristics:
• Measures burden of disease, not a measure of risk.
• Knowledge on onset of disease not needed.
Depends on:
1. Number of people who has been ill in the past.
2. Duration of illness.
Two ways of expression
point prevalence
Period prevalence
 Prevalence

Proportion of population that has disease at a particular time.

Includes both new and old cases.

Assess the burden of disease.

Useful when assessing the needs of health services.

Usually expressed as percentage

Period prevalence Point prevalence

measures the frequency of existing disease in
The point in time is broader
a defined population at a single point in time.

E.g. duration of eye screening for cataract = 3 E.g. Of 10,000 female residents in town A on
years, 2015 – 2017 January 1 2006, 1,000 have hypertension.

Total number of people screened = 2477 The prevalence of hypertension among

Total number of people with cataract = 310 women in town A on this date is calculated
as:
Therefore, period prevalence = 310/2477 =
12.5% 1,000/10,000 = 0.1 or 10%

Ways of expressing: 12.5%, 0.125, 12.5 per Other ways of expressing = 1 per 100
100 population or 1.25 per 1000 population. population, 0.1 per 1000 population.
Relationship between Incidence and Prevalence

𝑃=𝐼𝑋𝑑

P = Prevalence
I = Incidence
D = duration
 Issues of using incidences and prevalence

Problems with numerators

Definition of disease may be different in different places. Inclusion or not of a
suspected disease can affect the values of incidence and prevalence.

Problems with hospital data

Hospital data is an important source to calculate incidence and prevalence. Problems
that could contribute in calculating the incidence and prevalence of disease include;
1. Selective admission – may be based on admission policy, severity of diseases,
associated medical condition., private vs public?
2. Hospital records are not research data. Records may be incomplete, illegible or
missing. Diagnostic quality may be different.
Issues of using incidences and prevalence
Problems with denominator
Points of catchment ie hospitals do not have (impossible!) a
defined catchment area. Imported cases may be included in
the database and does not reflect the incidence and
prevalence of the intended population. Selective
undercounting of certain group – esp minority group - may
occur as most of the time we look at the population as a whole
or the major population. Different definitions may be a
problem for comparisons later.

Definition is important!
The inclusion of women (who are at risk to develop cervical
cancer) who had undergone hysterectomy lowers the incidence
rates of women with cervical cancer. The dilution effect has been
removed and thus higher incidence rate of cervical cancer.
Issues of using incidences and prevalence
The rate of extramarital live births seems
increasing and worrying based on this
prevalence rate.

The increased prevalence of extramarital

live birth was due to the reduction in
number of live births to married women.
Crude, Specific
and Adjusted
Rates
Disease measures 3
• Any rate can be expressed for a total population (crude and adjusted)
or for a population subgroups (specific rates)
• Crude rates – based on actual number of events (eg birth, death,
disease) in a total population over a given time period.
• Adjusted rates – summary rates that have gone statistical
transformation to permit fair comparison between groups (another
session).
 Crude Rates
• Widely used: crude birth rate and crude death rate.
• 2 factors contribute to crude rates:
• Probability of dying for individuals
• Age distribution of the population
• Formula for Crude Birth Rate =
number of live birth to residents in an area in a calendar year
/1000
Average population in the area in that year

• Formula for Crude Death Rate =

number of 𝑑𝑒𝑎𝑡ℎ to residents in an area in a calendar year
/1000
Average population in the area in that year
 Adjusted Rates
• This will be covered in another session.
• Like crude rate, has one summary figure.
• Statistical procedure applied remove differences.
• Age is commonly controlled for.
• 2 methods used – direct and indirect method.
 Specific Rates
• Example – age specific death rate (25-24 years)

number of 𝑑𝑒𝑎𝑡ℎ 𝑎𝑚𝑜𝑛𝑔 𝑟𝑒𝑠𝑖𝑑𝑒𝑛𝑡𝑠 𝑎𝑔𝑒𝑑 25−34 in an area in a calendar year

X1000
Average population age 25−34 in the area in that year
 Advantages vs Disadvantages
Advantages Disadvantages
Crude Rates Actual summary rates Difference in crude rates are
Readily calculable for difficult to interpret since the
international comparisons population vary in composition
(widely used despite
limitations)

Specific Rates Homogenous subgroups Cumbersome to compare many

Detailed rates are useful for subgroups of 2 or more
epid and public health purposes populations

Adjusted Rates Summary statements Fictional rates

Differences in composition is Dependent on standard
removed permitting unbiased population chosen
comparison Opposing trends in subgroups
masked.
Measures of Association
More in Epid study designs
 Relative Risk
Outcome
+ ve - ve • Ratio of incidence of disease in exposed
+ ve A B subjects to non exposed subjects.
Risk
- ve C D
• Formula for RR:
𝐴 (𝐴+𝐵)
•
𝐶 (𝐶+𝐷)

• Used in cohort study

• Interpretation:
• RR = 1.0: the incidence rate of outcome are
the same for exposed and non-exposed
group.
• RR > 1: Exposure indicates increased risk.
• RR < 1: Exposure decreases the risk of
developing the disorder.
 Lung Cancer
total
Yes No
Yes 70 60 130
Smoking
No 20 90 110
total 240

• Calculate the RR:

• Recall formula – [a/(a+b)] / [c/(c+d)]
• 0.538 / 0.182 = 2.956
• People who smoked are three times likely to develop lung cancer.
 Odds Ratio
Outcome
• Concept of odds: success / failures
+ ve - ve
+ ve A B
• OR = the ratio of odds.
Risk
- ve C D
• Odds of disease in exposed: A / B
• Odds of disease in non-exposed: C / D
• OR = (A/B) / (C/D) = AD / BC
• Used in case control study to estimate RR
• CC cannot determine incidence
• Interpretation:
• OR = 1.0: the odds of outcome are the same
for exposed and non-exposed group.
• OR > 1: Exposure indicates increased odds for
disease.
• OR < 1: Exposure decreases the odds for
disease
 Attributable Risk (AR)
• Other name: Cumulative incidence
• Measures the proportion of disease in a population that can be
attributed to the exposure
• Formula:
• Incidence of disease in exposed group – incidence of disease in the
unexposed group.
 Lung Cancer
total
Yes No
Yes 70 60 130
Smoking
No 20 90 110
total 240

• Overall Risk:
• 90 / 240 = 0.375 = 37.5%
• Absolute risk for lung cancers for smokers
• 70 / 130 = 0.538 = 54%
• Absolute risk for lung cancers for non smokers
• 20 / 110 = 0.182 = 18%
• Attributable Risk (AR): 0.538 – 0.182 = 0.356 = 36% of lung cancer is attributed to
smoking
 Other Measures of Association
• Absolute Risk Reduction (ARR)
• Risk of disease in untreated – risk of disease in treated group.
• measures the disease risk differences between treated and untreated groups.
The concept is almost similar to the Attributable Risk calculation.
• Relative Risk Reduction (RRR)
• ARR / incidence on control group
• by how much the treatment reduced the risk of bad outcomes relative to the
control group who did not have the treatment.
• Numbers needed to Treat (NNT)
• 1 / ARR
• Nearer to 1, the better.
• number of patients who need to be treated to prevent one bad outcome
 Migraine
Yes No
Drug 20 60
Rx
Relax 70 90
ARR
= 70/160 – 20/80 = 0.4375 – 0.250 = 0.1875. there is 18% reduction of migraine in the drug group.

RRR
= ARR / incidence in control group = 0.188 / 0.4375 = 0.4286. There is a 42.9% reduction in the
treatment arm.

NNT
= 1/ ARR = 1/0.188 = 5.3. You need to treat 5 patients before seeing one treated. Or you need to
treat 5 patients to achieve one beneficial outcome or to prevent one adverse outcome.
Selected indices of health
 Selected indices of health
• Rates whose denominators are total population
• Crude birth rate (per 1000 pop)
• Crude death rate (per 1000 pop)
• Age specific death rate (per 1000 pop)
• Cause specific death rate (per 100,000 pop)
• Rates and ratios whose denominators are live birth (per 1000 live birth)
• Infant mortality rate
• Neonatal mortality rate
• Fetal death ratio
• Maternal mortality rate
• Under 5 mortality rates (MDG 4 target)
• Rates whose denominator are live birth and fetal death (per 1000 live birth
and fetal death)
• Fetal death rate
• Perinatal mortality rate
Cause Specific Indices – cause specific death rate
• Formula: Cause Specific Death Rate
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ 𝑓𝑟𝑜𝑚 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑐𝑎𝑢𝑠𝑒
x 100,000.
𝑚𝑖𝑑 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
• Example 1.
• Mid year population = 5,000,000
• Deaths due to road accident = 4,000
• Cause specific death rate = (4000 / 5,000,000) x 100,000 = 80 deaths per 100,000
pop.
• Example 2:
• Annual Mortality rate for TB among children less than 10 year old
N𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡h𝑠 𝑓𝑟𝑜𝑚 TB 𝑖𝑛 one 𝑦𝑒𝑎𝑟 𝑖𝑛 𝑐h𝑖𝑙𝑑𝑟𝑒𝑛 𝑙𝑒𝑠𝑠 𝑡h𝑎𝑛 10 𝑦𝑒𝑎𝑟𝑠
𝑁𝑜 𝑜𝑓 𝑐h𝑖𝑙𝑑𝑟𝑒𝑛 𝑖𝑛 𝑡h𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑦𝑜𝑢𝑛𝑔𝑒𝑟 𝑡h𝑎𝑛 10 𝑦𝑒𝑎𝑟𝑠 𝑎𝑡 𝑚𝑖𝑑 𝑦𝑒𝑎𝑟
x 1000

• Problems:
• Inaccurate numerator and denominator – difficulty in assigning cause of death,
under-reporting in certain segments of the population.
 Proportionate Mortality Ratio (PMR)
• Formula
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ 𝑓𝑟𝑜𝑚 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑐𝑎𝑢𝑠𝑒 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
per 100
𝑡𝑜𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑

• Often confused with cause specific death rate.

• A ratio. Not a rate.
• Denominator – the deaths, not population at risk.
• Answers the question:
• What proportion of death is attributable to disease X?
 Case Fatality Rate
• Refers to the rate of death in persons diagnosed with a specific
disease.
• It is a measure of severity of disease. Used to measure the effects of a
new therapy too.
• Formula:
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ 𝑓𝑟𝑜𝑚 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
X 100
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑖𝑛𝑑𝑖𝑣𝑖𝑑𝑢𝑎𝑙𝑠 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑑𝑖𝑠𝑒𝑎𝑠𝑒

• Answers:
• What percentage of people who have a certain disease die within a certain
time after their disease was diagnosed?
 Case Fatality Rate
• A low prevalence of a disease does not mean that is it less severe.
Consider the following;

• Population: 1000 people.

• Number with disease X in 2014: 20
• Number who died due to disease X in 2014: 18
• The prevalence of disease = 0.02 per 1000 population.
• The mortality rate of disease X = 0.018 deaths per 1000
• The case fatality rate of disease X = 90%
 Specific Mortality Rates
Infant mortality Number of infant deaths in given year / number of live A measure of risk. Influenced by birth
rates birth in that year x 1000 rate. Major determinant of life
expectancy at birth. Good indicator
for overall health status of a pop.
Sensitive to levels and changes in
Socio Economic changes.
Perinatal Number of fetal deaths 20 weeks or more gestation plus Reflects events during pregnancy and
mortality rate number of neonatal death (28 days or less in age) in a after birth.
given in a given period / number of fetal deaths 20 weeks
or more gestation plus number of live birth in the same
period x 1000
Neonatal Number of neonatal deaths (<28 days OL) in a given Estimates events occurring
mortality rate period / number of live births in that period x 1000 immediately after birth – congenital
malformation, prematurity, LBW etc.
Under 5 Number of deaths in children under 5 years / number of MDG indicator goal 4 – reducing child
mortality rates live births x 1000 mortality.
 Specific Mortality Rates
Maternal (Number of maternal death in a specified period of time / Measure obstetrics risk – the risk of
mortality ratio Number of live birth in a population of a given area during dying in a pregnant woman.
that specific period of time) x 100,000
Maternal (# of maternal death / # of woman age 15 -49 ) x 100,000 Represents both the obstetric risk
mortality rate and the frequency with which
Death of a woman while pregnant or within 42/7 TOP. women are exposed to this risk
Irrespective of the duration and site of pregnancy.
From any cause related to or aggravated by the pregnancy
and its management.
Not from accidental causes.
Specific Mortality Rates
Some definitions related
to maternal and child
mortality rates.
 Years of potential life loss (YPLL)
Another form of mortality index.
Estimate the duration of time a person would have lived if he / she had not died prematurely.
Deaths occurring in the same person at a younger age involves a greater loss of future productive
years than were it to occur at an older age. It is used to sum data by leading cause of death and
ranking it to show the highest number of YPLL for a specific geographical area / demographic.

YPLL before age 65 among children less than 20

years from injuries and other diseases.

The highest YPLL comes from injuries. The total

YPLL for injuries is equal to YPLL for congenital
anomalies and prematurity combined. Injuries
should be address to address YPLL in children.
 Mortality rate finer points
• An index of disease severity and risk of disease.
• Not a good index of incidence in mild and not fatal disease.
• Good reflection of incidence rate if case fatality rate is high and when
the duration of disease is short.
• Problems with the numerator
• Errors in diagnosis, errors in age, changes in coding and changes in
classification.
• Problems with the denominator
• Errors in counting the population, errors in classifying by demographic
characteristics (age, sex, race) and difference in percentages of population at
risk.
 Errors
• Random error
• Fluctuation around the true value because of sampling variability.

• Systematic error
• Bias.
• More dangerous. Difficult to measure.
 Sources of Errors
Use of non random samples of the target population
Deriving that the population has high income when samples are taken from shopping complexes.

Non participation members of the target group

Refusal or not available in a study / data collection. Eg: healthy worker effect – deriving that workers
are generally healthy when those who are on sick leave are not accounted for.

Observer variation
Different interpretation due to different protocols, tools or technique.
 Sources of Errors

Different response pattern

Based on different situation. Better compliance reported after educating on compliance, high
cholesterol levels within one month of Gawai etc.

Variation in perception of illness

Illness behaviour. A sick person may keep his illness to himself, see a doctor (contribute to morbidity
rates) or take sick leave (contribute to days lost from work). The reason is multiple – culture, past
history, any benefits entrusted etc.

Variation in availability of treatment resources

The number of cancers detected is higher in a district with cancer treatment facility than a district
without one.