APPLIED

EPIDEMIOLOGY
Nesidai
Introduction Lecture 1

3/6/15

Objectives
By the end of the lesson, the learner should be able to:
Define

epidemiology

Terminologies
Summarize

the historical evolution of epidemiology

(Hand out)
Describe

the elements of a case definition and state

the effect of changing the value of any of the elements
Uses

of Epidemiology
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 The

word epidemiology comes from

the Greek words epi, meaning on or
upon, demos, meaning people,
and logos, meaning the study of.
Many definitions have been
proposed, but the following definition
captures the underlying principles
and the public health spirit of
epidemiology:
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 Epidemiology

is the study of the

distribution and determinants of

health-related states or events in
specified populations, and the
application of this study to the
control of health problems.
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Terminologies

Study. Epidemiology is a scientific discipline, sometimes

called the basic science of public health. It has, at its
foundation, sound methods of scientific inquiry.

Distribution. Epidemiology is concerned with the

frequency and pattern
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Distribution. Epidemiology is concerned with the

frequency and pattern of health events in a population.

Frequency includes not only the number of such events in a

population, but also the rate or risk of disease in the
population. The rate (number of events divided by size of
the population) is critical to epidemiologists because it
allows valid comparisons across different populations.

Pattern refers to the occurrence of health-related events by

time, place, and personal characteristics.
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Time characteristics include annual occurrence, seasonal

occurrence, and daily or even hourly occurrence during an
epidemic.

Place characteristics include geographic variation, urbanrural differences, and location of worksites or schools.

Personal characteristics include demographic factors such

as age, race, sex, marital status, and socioeconomic status,
as well as behaviors and environmental exposures

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This characterization of the distribution of healthrelated states or events is one broad aspect of
epidemiology called descriptive epidemiology.
Descriptive epidemiology provides the What, Who,
When, and Where of health-related events.

Determinants. Epidemiology is also used to search

for causes and other factors that influence the
occurrence of health-related events. Analytic
epidemiology attempts to provide the
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Why and How of such events by

comparing groups with different rates of
disease occurrence and with differences
in demographic characteristics, genetic or
immunologic make-up, behaviors,
environmental exposures, and other socalled potential risk factors.
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Under ideal circumstances, epidemiologic

findings provide sufficient evidence to direct
swift and effective public health control and
prevention measures

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Health-related states or events.

Originally, epidemiology was concerned
with epidemics of communicable diseases.

Then epidemiology was extended to

endemic communicable diseases and noncommunicable infectious diseases.

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More recently, epidemiologic methods

have been applied to chronic diseases,
injuries, birth defects, maternal-child
health, occupational health, and
environmental health

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Now, even behaviours related to health

and well-being (amount of exercise, seatbelt use, etc.) are recognized as valid
subjects for applying epidemiologic
methods.

disease. Refer to the range of healthrelated states or events.

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Specified populations. Although epidemiologists

and physicians in clinical practice are both
concerned with disease and the control of disease,
they differ greatly in how they view the patient.

Clinicians are concerned with the health of an

individual; epidemiologists are concerned with
the collective health of the people in a
community or other area.
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When faced with a patient with diarrheal

disease, for example, the clinician and the
epidemiologist have different responsibilities.
Although both are interested in establishing
the correct diagnosis, the clinician usually
focuses on treating and caring for the
individual.
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The epidemiologist focuses on the exposure

(action or source that caused the illness), the
number of other persons who may have been
similarly exposed, the potential for further
spread in the community, and interventions to
prevent additional cases or recurrences.

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Application. Epidemiology is more than the study

of. As a discipline within public health,
epidemiology provides data for directing public
health action. However, using epidemiologic data is
an art as well as a science. Consider again the
medical model used above: To treat a patient, a
clinician must call upon experience and creativity
as well as scientific knowledge.
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Similarly, an epidemiologist uses the

scientific methods of descriptive and
analytic epidemiology in diagnosing
the health of a community, but also must
call upon experience and creativity
when planning how to control and
prevent disease in the community.
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Other definitions of terms

Data-Raw facts and figures
Information-analyzed and interpreted data
Health information systems- organized set of
activities and programs whose purpose is to
gather, maintain, and provide health related
information to improve individual or
population health
Vital statistics- combination of vital and
health statistical data-mortality, morbidity,
life expectancy, births, marriages, divorces,
census
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Rates- amount or number of one thing measured in units

of another
- Measure of an event/condition with a unit of
population and within a time period
- No of cases/population of area in time x 1,000
Crude rates- Number of events that happen in population
in certain period of time
Define the following terms:
Infant mortality rates
Neonatal mortality rates
Postneonatal mortality rates
Maternal mortality rates
Perinatal mortality rates

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Data sources
Registration systems
Vital-event registration
Disease notifications
Sentinel notifications
Studies
Surveys
Registries
Epidemic investigations
Population & house census
research

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Other
Administrative
Program evaluation
Public health surveillance
Exit interviews & FGD
Other data banks

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Uses of Epidemiology
Monitoring the health of a community,
region, or nation
Surveillance, accident reports
Identifying risks in terms of probability
statements
Studying trends over time to make
predictions for the future
Smoking and lung cancer
Estimating health services needs

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The Epidemiologic Triad:

Agent, Host, and Environment
The epidemiologic triangle or triad is the
traditional model of infectious disease
causation. It has three components: an
external agent, a susceptible host, and an
environment that brings the host and
agent together. In this model, the
environment influences the agent, the
host, and the route of transmission of the
agent from a source to the host.
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Agent factors
Agent originally referred to an infectious micro-organism
virus, bacterium, parasite, or other microbe.
Agents must be present for a disease to occur i.e they are
necessary but not always sufficient to cause disease.
As epidemiology has been applied to non-infectious
conditions, the concept of agent in this model has been
broadened to include chemical and physical causes of
disease. These include chemical contaminants, such as the
l-tryptophan contaminant responsible for eosinophilia
myalgia syndrome, and physical forces, such as repetitive
mechanical forces associated with carpal tunnel syndrome.
NB: it is not always clear whether a particular factor should
be classified as an agent or as an environmental factor.

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Host factors
Host

factors are intrinsic factors that influence an individuals

exposure, susceptibility, or response to a causative agent.
Age,

race, sex, socioeconomic status, and behaviours

(smoking, drug abuse, lifestyle, sexual practices and
contraception, eating habits) are just some of the many host
factors which affect a persons likelihood of exposure.
Age,

genetic composition, nutritional and immunologic

status, anatomic structure, presence of disease or medications,
and psychological makeup are some of the host factors which
affect a persons susceptibility and response to an agent.
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Environmental factors
Environmental

factors are extrinsic factors which affect the

agent and the opportunity for exposure.
Generally,

environmental factors include physical factors

such as geology, climate, and physical surroundings (e.g., a
nursing home, hospital); biologic factors such as insects that
transmit the agent; and socioeconomic factors such as
crowding, sanitation, and the availability of health services.
Agent,

host, and environmental factors interrelate in a variety

of complex ways to produce disease in humans. Their balance
and interactions are different for different diseases.
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END

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MEASURES OF
ASSOCIATION/IMPACT/OUTCOME
MEASURES LESSON 2

By Nesidai

3/6/15

31

MEASURING EPIDEMIOLOGICAL OUTCOMES

Relationship between any two numbers
(e.g. males / females or x/y) The
Ratio
numerator is not included in the
denominator
A ratio where the numerator is
Proportion
included in the denominator
(e.g. males / total births)

Rate

A proportion with the specification of time

(e.g. deaths in 2000 / population in 2000)
By Nesidai

3/6/15

32

OUTCOME MEASURES
Compare

the incidence of disease among people who

have some characteristic with those who do not

The

ratio of the incidence rate in one group to that in

another is called a rate ratio or relative risk (RR)

The

difference in incidence rates between the groups is

called a risk difference or attributable risk (AR)

By Nesidai

3/6/15

33

CALCULATING OUTCOME MEASURES

Outcome
Exposure
Exposed
Not Exposed

Disease
(cases)

No Disease
(controls)

Incidence

IE = A / (A+B)

IN = C / (C+D)

Relative Risk = IE / IN
Attributable Risk = IE - IN
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By Nesidai

34

Lung Cancer
Exposure

Yes

No

Total

Incidence

Smoker

70

300

370

70/370 = 189 per 1000

Non-smoker

30

700

730

30/730 = 41 per 1000

100

1,000

1,100

Relative Risk = IE / IN = 189 / 41 = 4.61

Attributable Risk = IE - IN = 189 - 41 = 148 per
1000
3/6/15

By Nesidai

35

Relative Risk = IE / IN = 189 / 41 = 4.61

Attributable Risk = IE - IN = 189 - 41 = 148 per
1000

Smokers are 4.61 times more likely than

nonsmokers to develop lung cancer

148 per 1000 smokers developed lung cancer

because they smoked
By Nesidai

3/6/15

36

RR < 1

RR = 1

RR > 1

Risk
comparison
between
exposed and
unexposed

Risk for disease

is lower in the
exposed than in
the unexposed

Risk of disease
are equal for
exposed and
unexposed

Risk for disease

is higher in the
exposed than in
the unexposed

Exposure as a
risk factor for
the disease?

Exposure
reduces disease
Particular
risk
exposure is not a
risk factor
(Protective
factor)

3/6/15

By Nesidai

Exposure
increases
disease risk
(Risk factor)

37

ANNUAL DEATH RATES FOR LUNG CANCER AND CORONARY HEART DISEASE (CHD)
BY SMOKING STATUS, MALES

Annual Death Rate / 100,000

Coronary Heart Disease

Exposure

Lung Cancer

Smoker

127.2

1,000

Non-smoker

12.8

500

RR

127.2 / 12.8 = 9.9

1000 / 500 = 2

AR

127.2 12.8 = 114.4 per

100,000

1000 500 = 500

per 100,000

By Nesidai

3/6/15

38

SUMMARY
The

risk associated with smoking is lower for CHD

(RR=2) than for lung cancer (RR=9.9)

Attributable

risk for CHD (AR=500) is much higher

than for lung cancer (AR=114.4)

In

conclusion: CHD is much more common (higher

incidence) in the population, thus the actual
number of lives saved (or death averted) would be
greater for CHD than for lung cancer
By Nesidai

3/6/15

39

ODDS RATIO

Disease

Odds of disease
having exposure

Exposure
Odds of
exposure having
disease

a+b

c+d

a+c

b+d

a+b+c
+d

ODDS RATIO
-The ODDS of getting disease in exposed
=a
b
- The ODDS of getting disease in unexposed = c
d
ODDS RATIO = (a/b)/(c/d) = axd
cxb
(Cross-products Ratio)

FACTORS CONTRIBUTING TO THE

EMERGENCE AND RE-EMERGENCE OF
INFECTIOUS DISEASES

Microbial

adaption; e.g. Natural

genetic variations, recombinations

and adaptations e.g Influenza A
Changing

human susceptibility; e.g.

mass immunocompromisation with

HIV/AIDS

Climate and weather; e.g. diseases

with Zoonotic vectors such as West
line Disease (transmitted by
mosquitoes) are moving further from
the tropics as the climate warms

Economic development; e.g. use of

antibiotics to increase meat yield of farmed
cows leads to antibiotic resistance

Breakdown of public health

Poverty and social inequality; e.g. TB is

primarily a problem in low-income areas

Change in human demographics and

trade; e.g. rapid travel enabled SARS to
rapidly propagate around the globe

War and farmine

Bioterorism; e.g. 2001 Anthrax attacks

Dam and irrigation system

construction; e.g. malaria and other
mosquito borne diseases

Increasing

trade in exotic animals for pets

and as food sources. eg, recent U.S. outbreak

of monkeypox, and use of exotic civet cats
for meat in China was found to be the route
by which the SARS coronavirus made the
transition from animal to human hosts.

Increased

and imprudent use of drugs

and pesticides has led to the devpt of

resistant pathogens, allowing many
diseases that were formerly treatable to
make a comeback (e.g. TB, malaria,
nosocomial, and food-borne infections)

Decreased compliance with

vaccination policy has also led to reemergence of diseases e.g. measles
and pertussis

Moreover, many important infectious diseases

have never been adequately controlled on
either the national or international level.
Infectious diseases that have posed ongoing
health problems in developing countries are
re-emerging in theUnited States(e.g., foodand waterborne infections, dengue, West Nile
virus).

MEASURES OF DISEASE
OCCURRENCE
NESIDAI LECTURE 3

These mainly refer to morbidity and mortality measures.

MORBIDITY:

- Describes frequency of illness within populations.

- Commonly used measures:

Incidence and Prevalence rates.

Note the most important tool for measures of disease is

the RATE. The RATIO and PROPORTION are also often
used.

RATIO:
Is

the Relationship between any two numbers

(e.g. males / females)
Its the Simplest of the expressions.
Expresses a relationship in form of X : Y or
X/Y
e.g. M:F.
Males and Females are exclusive. What is in
M is not included in F. (M/F)

PROPORTION:

Its a ratio where the numerator is included in the

denominator (e.g. males / total births)
Usually expressed as % e.g.
Proportion of all births that are male
= Male births
Male + Female births

RATE:
A

proportion with the specification of time

(e.g. deaths in 2000 / population in 2000)
Rate important for disease measurement because it
gives probability or risk of disease in a defined
population in a specified period of time.
Rate:
= No of events in given time in a given population X k
Pop. at risk of event in same time in same pop.

INCIDENCE:
Incidence is the rate of new cases of a disease or
condition in a population at risk during a time period
Deals with new cases of disease or event during
specified period of time.
It measures probability that healthy people will develop
disease in specified time period.
Population is disease free at the beginning of
observation period.
Incidence is a rate
Calculated for a given time period (time interval)
Reflects risk of disease or condition

INCIDENCE DEFINITION:

Incidence (per 1000)

= No. of new cases in given time period X k
Pop. at risk of disease in same time

Choice of 1,000 (k) in the rate is arbitrary

Incidence is a rate
Calculated for a given time period (time interval)
Reflects risk of disease or condition

Numerator = only events or disease cases

developed within specified time

period.

Denominator = All at risk in specified time.

Those included must have potential of developing disease

e.g. Cancer Cervix

INCIDENCE DEFINITION CONT:

However, most diseases have low frequency and

in most cases we deal with large pop. Difference
in excluding/including the immunized is of little
statistical significance.

If precision is required or condition is common,

then denominator includes only those at risk e.g.
measles vaccine trials. At risk, those who have
not had measles.

TYPES OF INCIDENCE.
Attack Rate is another type of incidence (So is 20
attack rate.)
Attack Rate is incidence of disease when pop. at
risk is exposed for short time e.g. Epidemics (Food
poisoning).
20 Attack Rate - Measures No. of cases of disease
developing during stated time among those in a
closed group who are susceptible.
It measures infectivity of disease.
= No of new cases in grp minus No of initial cases
No of susceptible in grp minus initial cases

CUMULATIVE INCIDENCE AND

INCIDENCE DENSITY

Sometimes period time over which persons are

observed may vary due to deaths, varying joining
time in study.
Person - time denominators are then used.
Here each case contributes unequal time to study.
All must be included. The person time unit is thus
created.
There are 2 types of incidence measures:
- Cumulative Incidence (CI)
- Incidence Density (ID).

CUMULATIVE INCIDENCE AND INCIDENCE DENSITY

Cumulative Incidence:

= No of new cases of disease in given period of time X 1,000

Total pop. At risk during same time

It estimates probability or risk that one will be sick in

given period of time.
Incidence Density:
= No of new cases in given period of time
Total person - time of observation

INCIDENCE DENSITY

Person-time is valid when:

- Risk of death or disease is constant through out
study.
- Disease or death rates are the same all through
i.e. for those still in study and
those lost to follow
up.

SUMMARY INCIDENCE :

It measures rapidity with which disease develops in

pop.
It is a more useful measure of risk cause it has
measure of time. It is thus a true rate.
It is direct indicator of risk of disease.
It indicates pop. free of disease at stat. of observation
time developing disease during observation.

INCIDENCE CONT:

Incidence is used in aetiologic studies of both chronic and acute forms

(e.g. Snow & cholera)

Increasing incidence rates provide clues on disease aetiology especially

if one can determine the exposures that occured before onset of
disease.

Decreasing incidence rates may be due to results of disease control or

prevention programme, or may be due to changes in host or agent
characteristics (resistance / immunity).

Increasing incidence rates might suggest:

- Need for new control or prevention programme.
- That reporting practices improved.
- That diagnostic procedure are more sensitive
- Or ALL.

INCIDENCE CONT:

To determine incidence, must be able to classify

subjects into diseased or not diseased.

Screening method is therefore necessary

PREVALENCE:
Prevalence is the proportion of the population affected
About existing disease cases in pop. at point in time or
specified period of time.
Prevalence is a proportion
Point Prevalence: at a particular instant in time
Period Prevalence: during a particular interval of time
(existing cases + new cases)
Measures those already with disease i.e. gives the
probability that person has disease at a given time.
Cases included are both old and new.
Prevalence depends on:
- Rate of Cure
- Recovery
- Death

Prevalence is a proportion
Point

Prevalence: at a particular instant in

time
Period

Prevalence: during a particular

interval of time (existing cases + new cases)

Prevalence= Number of existing cases

Total number in the population at risk

PREVALENCE CONT:

Prevalence thus reflects the incidence and

duration of disease.
In a stable pop. :
- Prevalence = Incidence X Average duration of
disease
Prevalence describes amount of disease in pop. at
point in time or period interval in time.
It does not measure rate of development of
disease.
It is more correctly a ratio or proportion.

INCIDENCE AND PREVALENCE :

Incidence adds cases to prevalence:

When incidence increrases, shows Risk.
When prev. decreases, it shows cure or death.
Prevalence may increases when cases not dying
but disease controlled e.g. insulin and diabetes.
When prevalence is increasing, difficult to
convince that programme is working.
Disease may be controlled, but cure not achieved.
Health resource requirements & planning is
determined by this.

PREVALENCE CONT

If type of prevalence is not mentioned, then regard it as point

prevalence.

In prevalence, onset of disease does not need to be known while in

incidence it is necessary.
Period prevalence is preferred than point prevalence or incidence
because of establishing date on which disease started e.g. mental
illnesses.

Prevalence is useful in:

- Chronic diseases
- Expressing burden of disease in pop.
- Monitoring Control Programmes cause it reflects on duration
and Incidence.
- High prevalence does not necessary signify raised risk. It may
mean longer survival of cases.

INCIDENCE AND PREVALENCE ILLUSTRATION:

1995 - Incidence
=b+d
Point prevalence = (depends on which month count
is made.
- January = a + c + e
- May =
A+ b + c + e
- July B+c+d+e
- September = b + d + e
- December = d + e
Period prevalence (1995) = a + b + c + d + e

PROBLEMS WITH INCIDENCE AND PREVALENCE

MEASURES:
Defining who has disease (Numerator)
Prevalence can be affected by diagnostic criteria used.
Finding cases for inclusion:
- By interview
- By data collected regularly (E.g. Hospital - Problems)
Hospital admissions selective on:
- Personal characteristics
- Severity of disease
- Admission policies.
Comparability of cases (e.g. primigravidae in KNH, others).
Hospital rates have no denominator, i.e no catchment pop.
Denominator must be described well.
In ca. Cervix denominator must exclude

RATES:

CRUDE
SPECIFIC
ADJUSTED

CRUDE RATES:
These dont take into consideration certain crucial
factors that impact on the rate. E.g. Age, sex, place.

Specific Rates:
These take into consideration these factors.

ADJUSTED RATES:
Undergo statistical transformation to
permit fair comparison between grps
which differ in some characteristic
that may affect risk of disease.
Transformation is carried out on crude
rates to remove the effect of
differences in composition of the
various pops.

ADJUSTED RATES:
Adjustment is done cause pop.
compositions in two different periods
may differ.
One may have older people which
affects mortality.
Adjustment removes the influence of
age on rates being compared.
Exercises Handout

TABLE 1:
COMPARABILITY OF 2 POPULATIONS WITH SAME AGE STRATA

Population as of July,
Population as of July,
1st, 1940
1st, 1980
Age grp
(Yrs). (1)
(2)
_______________________________________________________________________
<5
5-9
10
15
20
25
30
35
40
45
50
55
60
65
75+

10,541
16, 348,000
10,685
16, 700,000
14
11,746
18, 242,000
19
12,334
21, 168,000
24
11,588
21, 319,000
29
11,097
19, 521,000
34
10,242
17, 561,000
39
9,545 13, 965,000
44
8,788 11, 669,000
49
8,255 11, 090,000
54
7,257 11, 710,000
59
5,844 11, 615,000
64
4,728 10, 088,000
74
6,377 15, 581,000
2,643 9, 969,000

Total 131,670

226,546,000

TABLE 2:
COMPARISON OF 2 POPULATIONS FOR SPECIFIC AND CRUDE CANCER MORTALITY
RATES:

Cancer Mortality Rates per 100,000

_________________________________________
(Yrs). (1940)
(1980)
_______________________________________________________________________
<5
5-9
10
15
20
25
30
35
40
45
50
55
60
65
75+

4.7 4.2
3.0 4.7
14
2.9 3.9
19
4.0 5.4
24
6.8 7.2
29
11.6 10.5
34
23.5 17.3
39
43.4 33.5
44
80.3 66.9
49
133.4 128.3
54
209.0 228.9
59
309.9 358.2
64
443.3 25.8
74
695.1 817.9
1183.5
1313.7

Total 120.2 183.8

ADJUSTED RATES

E.g. Crude mortality rate from cancer in USA in 1940 was 120.2 per
100,000 and in 1980, rate was 183.8 per 100,000.
When compare the 2 rates it suggests that, the rate is increased
alarmingly by 53% (This is an epidemic).

(183.8 120.2 =
63.2 X 100 )
120.2
Problem of comparing the 2 directly is that;
In 1980, 11% of the population was 65 years or older while in 1940,
this proportion was 6.9%. (i.e. the population in 1980 is older

Mortality rates from most cancers increase dramatically with age.

The higher crude cancer mortality rates are attributed in part, at

least, to ageing of the population.

ADJUSTED RATES CONT.:

Thus any crude rate is a

Weighted average of individual age category specific rates
Weight here is the proportion in the pop. that each age
category contributes to total rate.
Thus if < 5 yrs are 1,000,000 then more deaths will be
recorded than if the total pop. is 100,000.
Thus if 2 pops have the same stratum specific rates, the 2
will differ in crude rates if proportion (number) of pops
within each of the various categories are different.

ADJUSTED RATES CONT:

2 ways of accounting for different distributions of a

characteristic between populations being compared is

- Either present and compare only the category specific

rates
e.g. 1940 1980, though crude rates increased by 53%
most age specific rates increased only slightly,
- In fact for < 5 years and those between 25 and 49 years,
mortality rates actually decreased
Comparing specific rates is thus more accurate than the
crude rates.

ADJUSTED RATES CONT:

However one requires large numbers, each age group

has to be scrutinized and compared with another.
It becomes easier to have a summary rate to compare
with another.
Summary takes into account any differences in the
structure of a population.
The procedure used to do this is called Adjustment or
Standardization.

ADJUSTED RATES CONT..:

Adjusted rates are also standardized rates.

Age is variable for which most adjustment or
standardization is required.
2 ways of removing effect of differences in pop is
(Standardization):
- Direct method
- Indirect method

DIRECT METHOD CONT..:

Select standard Pop.

The standard pop. is arbitrarily selected.
Identify two grps being compared.
Then apply age specific mortality rates of each grp to
the pop. in same age grp of the standard pop.
This gives number of deaths that can be expected if
these age specific rates prevailed on the standard pop.

TABLE 3
CALCULATION OF CRUDE AND AGE SPECIFIC MORTALITY RATES FROM CANCER
(1980)

Age Number of Population as

Mortality rate per
Group (Years)
Cancer Deaths
of July 1, 1980
100,000
(1)
(2) (3)
____________________________________________________________________
<5
686 16,348,000
5 - 9 777 16,700,000
10 - 14
720
18,242,000
15 - 19
1145
21,168,000
20 - 24
1538
21,319,000
25 - 29
2041
19,521,000
30 - 34
3040
17,561,000
35 - 39
4684
13,965,000
40 - 44
7786 11,669,000
45 - 49
14,230
11,090,000
50 - 54
26,800
11,710,000
55 - 59
41,600
11,615,000
60 - 64
53,045
10,088,000
65 - 74
127,430
15,581,000
75 + 130,959
9,969,000
Total 416,481
226,546,000
(3) = (1) / (2)

TABLE 4
CALCULATION OF THE CRUDE CANCER MORTALITY RATE AS A
WEIGHTED AVERAGE OF AGE SPECIFIC RATES (1980)

Age Mortality rate per Population as

Number of
Group 100,000
of July 1, 1980
Cancer Deaths
(Years)
(1)
(2)
_____________________________________________________________________________
<5
4.2 (a)
16,348,000 (i)
5 - 9 4.7 (b)
16,700,000 (ii)
10 - 14
3.9 (c)
18,242,000 (iii)
15 - 19
5.4 (d)
21,168,000 (iv)
20 - 24
7.2 (e)
21,319,000 (v)
25 - 29
10.5 (f)
19,521,000 (vi)
30 - 34
17.3 (g)
17,561,000 (vii)
35 - 39
33.5 (h)
13,965,000 (viii)
40 - 44
66.7 (i)
11,669,000 (ix)
45 - 49
128.3 (j)
11,090,000 (x)
50 - 54
228.9 (k) 11,710,000 (xi)
55 - 59
358.2 (l)
11,615,000 (xii)
60 - 64
525.8 (m) 10,088,000 (xiii)
65 - 74
817.9 (n) 15,581,000 (xiv)
75 + 1313.7 (p)
9,969,000 (xv)
Total 226,546,000 (Z)
Crude 1980 cancer death rate = (1a) X (2i) + (1b) X (2ii) + (1c) X (2iii) .......... per 105
Z
= 183.8/105

TABLE 5
CALCULATION OF THE CRUDE CANCER MORTALITY RATE AS A WEIGHTED AVERAGE OF AGE
SPECIFIC RATES, WITH A DIFFERENT AGE DISTRIBUTION OF THE POPULATION. (1980)
Age Mortality rate per Population as
Number of
Group 100,000
of July 1, 1980
Cancer Deaths
(Years)
(1)
(2)
_____________________________________________________________________________
<5
4.2 (a)
16,348,000 (i)
5 - 9 4.7 (b)
16,700,000 (ii)
10 - 14
3.9 (c)
18,242,000 (iii)
15 - 19
5.4 (d)
21,168,000 (iv)
20 - 24
7.2 (e)
9,969,000 (v)
25 - 29
10.5 (f)
19,521,000 (vi)
30 - 34
17.3 (g)
17,561,000 (vii)
35 - 39
33.5 (h)
13,965,000 (viii)
40 - 44
66.7 (i)
11,669,000 (ix)
45 - 49
128.3 (j)
11,090,000 (x)
50 - 54
228.9 (k) 11,710,000 (xi)
55 - 59
358.2 (l)
11,615,000 (xii)
60 - 64
525.8 (m) 10,088,000 (xiii)
65 - 74
817.9 (n) 15,581,000 (xiv)
75 + 1313.7 (p) 21,319,000 (xv)
Total 226,546,000(Z)
Crude 1980 cancer death rate = (1a) X (2i) + (1b) X (2ii) + (1c) X (2iii) .......... per 105
Z
= 249.2/105

TABLE 6.
CALCULATION OF THE CRUDE CANCER MORTALITY RATE AS A WEIGHTED AVERAGE OF
AGE SPECIFIC RATES (1980)
Age Mortality rate per Population
Group
100,000 (1940) 1940 (in thousands)
(Years)
(1)
(2)
_____________________________________________________________________________
< 5 4.7 (a)
10,541 (i)
5-9
3.0 (b)
10,685 (ii)
10 - 14 2.9 (c)
11,746 (iii)
15 - 19 4.0 (d)
12,334 (iv)
20 - 24 6.8 (e)
11,588 (v)
25 - 29 11.6 (f)
11,097(vi)
30 - 34 23.5 (g)
10,242 (vii)
35 - 39 43.4 (h)
9,545 (viii)
40 - 44 80.3 (i)
8,788 (ix)
45 - 49 133.4 (j)
8,255 (x)
50 - 54 209.0 (k)
7,257 (xi)
55 - 59 309.9 (l)
5,844 (xii)
60 - 64 443.3 (m) 4,728 (xiii)
65 - 74 695.1 (n)
6,377(xiv)
75 +
1183.5 (p)
2,643(xv)
Total
120.2 131,670
Crude 1940 cancer death rate = (1a) X (2i) + (1b) X (2ii) + (1c) X (2iii) .......... per 105
Z
= 120.2/105

TABLE 7
CALCULATION OF THE AGE -ADJUSTED MORTALITY RATES FROM ALL
CAUSES BY THE DIRECT METHOD.
Standard Population:

Expected Number

Mortality from all

Causes per 100,000
Population

Total US Enumerated

population

Population Rates in

_________________ ___________________
Age

1950

Of Deaths that Would

Occur in Standar

1960

1940

1950

1960

(2)

(3)

(4)

(5)

_________________

Group
(Years) (1)

_____________________________________________________________________________
<1
1- 4

3,299.2

2,696.4

15,343 506.2 413.7

139.4 109.1 64,718

5 - 14

90.2

60.1 46.6 170,355

15 - 24 128.1 106.3

70.6

102.4

181,677

79.4
232.7

193.1

25 - 34 178.7 146.4 162,066

289.6

237.6

35 - 44 358.7

299.4 139,237

499.4

45 - 54 853.9

756.0 117,811

416.9
1,006.0

890.7

55 - 64 1,901.0

1,735.1

80,294

1,526.4

1,393.2

65 74 4,104.3

3,822.1

48,426

1,987.5

1,850.9

75 - 84 9,331.1

8,745.2

1,614.6

1,513.2

85+

20,196.9

17,303

19,857.5

2,770

559.5 550.4

Total death
rate all ages 963.8
Total Pop.

954.7

___

___ ___
1,000,000

___
___

___

Total Expected
Number of Deaths

____

____

____

____

8,414.5

7,609.7

Age Adjusted Death

Rate per 100,000

841.45

760.97

_____________________________________________________________________________
(4) = (1) X (3)
(5) = (2) X (3)

INDIRECT METHOD:
(STANDARDIZED MORT. RATIO)

Select a standard Pop. whose age specific death rates

are known.
Use this to calculate expected death rates in pop.
being compared.
Calculate S.M.R.
= Observed deaths X 100
Expected deaths

INDIRECT METHOD CONT:

Here compare 2 pops.

- One in which age specific death rates arent
known or if known are excessively variable because
of small numbers involved.
- Most stable rates of larger pop. are applied to
pop of smaller one.
Then calculate standardized mortality Ratio.

TABLE 6
CALCULATION OF THE STANDARDIZED MORTALITY RATIO FOR
OCCUPATION OF MALE FARMERS AND FARM MANAGERS FOR ALL
CAUSES OF DEATH .
Standard Death Rates
Expected Number
Number of Farmers
Per 1,000,000 (all
Of Deaths for farmers
And Farm Managers
causes of Death)
and farm managers
(Census 1951)
Per 1,000,000
Age
Group
(Years)
(1)
(2)
(3) = (1) X (2)
_____________________________________________________________________________
20 - 24
7,989
1,383
11
25 - 34
37,030
1,594
59
35 - 44
60,838
2,868
174
45 - 54
68,687
8,212
564
55 - 64
55,565
22,953
1,275
_____________________________________________________________________________
Total Expected Deaths per Year:2,083 (E)
Total Observed Deaths per Year:1,464 (O)
SMR = 1,464 X 100 = 70.3%
2,083

INDIRECT METHOD CONT:

S.M.R.
Column 1X column 2 = Column 3

= 2,083 Expected
Total observed is given 1,464
=
Observed - 1,464 X 100 = 70.3%
Expected - 2,083

PROPORTION V/S INCIDENCE

PROPORTIONS V/S INCIDENCE RATE CONT:

Line is incidence. Shows risk of breast cancer

throughout life.
It is computation of risk of cancer within age
group.
- At 45 yrs curve changes.
- Shows higher probability of cancer here
- This is pre and post menopause in women.
- Pattern is the same in women in all countries.
- Probably pre and post menopausal breast
cancers are different diseases.

PROPORTIONS AND INCIDENCE RATE:

Bar graph is % of total population with breast

cancer.
Trend is different in that it shows reduction with
age.
REASONS:
- Fewer older people exist and contribute a
small proportion to total.
- Hence only 5% of breast cancer cases occur
in oldest age grp.
- Gives impression that lesser attention
required at old age than the young