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Solomon Berhanu
October 14 2016
Outline
Basic Concepts (Introduction )
Measure of frequency
Measure of morbidity
Measure of mortality
Measure of association
Measure of disease impact
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Variable
A characteristic which takes different values in different
persons, places, or things
Any aspect of an individual or object that is measured
(e.g., BP, age, sex, Heart rate, Blood group... takes any
value)
Qualitative
Quantitative
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Variable
Quantitative variable: is one that can be measured in the
usual sense and Convey information regarding amount
E.G: heights of adult males, weights of preschool children
Average, mean, range, proportion are the possible summary
statistics
Qualitative variables: are not capable of being measured in
the sense that height, weight, and age are measured
Convey information regarding characteristics
Can be categorized only
E.g. A medical diagnosis, an ethnic group
Frequency, counting, proportion are the possible summary
statistics
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Measurement
Is the assignment of numbers to objects or events
according to a set of rules
It involves the concept of summarizing phenomena
quantitatively, numeracy
It is the process of specifying and operationalizing a given
concept
Health related event is measured on various levels (scale)
measurement
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Measurement cont
Epidemiology
The study of the distribution of health-related states and
events in populations
Intend to capture not only disease and illness, but
physiologic states such as blood pressure, psychological
measures such as depression score, and positive
outcomes such as disease immunity
The objective of epidemiologic research is to obtain a valid
and precise estimate of the effect of a potential cause on
the occurrence of disease, which is often a binary
(either/or) outcome
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MeasurementLevels/Scales
The most widely used classification of measurement
scales are:
Nominal scale;
Ordinal scale;
Interval scale; and
Ratio scale.
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MeasurementLevels/Scales
Nominal scale
The simplest type of data, in which the values fall into
unordered categories or classes
Consists of naming observations or classifying them into
various mutually exclusive and collectively exhaustive
categories
Uses names, labels, or symbols to assign each measurement
E.g. calculate averages, comparing with the numbers, use mode
as the measure of central tendency
Use Chi-square test
the least powerful(indicates no order or distance)
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MeasurementLevels/Scales
Ordinal scale
Places events in order, but there is no attempt to make the intervals
of the scale equal in terms of some rule
Have all of the requirements of nominal scales but also include the
property of order
Ordinal scales only permit the ranking of items from highest to lowest
Nothing is known about the size of the interval between any two
numerals
Median as measure of central tendency
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MeasurementLevels/Scales
Interval scale
Have all the requirements of ordinal scales with the added benefit
of distance between items
The distance between attributes does have meaning but has no
fixed zero(zero not indicate absence)
And ratio can meaningfully constructed
E.g. T0 210c-20oc=101oc-100oc but one cannot say that the T0 of
60 is twice as warm as the T0 of 30
Mean, standard deviation can be used
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MeasurementLevels/Scales
Ratio scale
Measurement begins at a true zero point and the scale has
equal space
This has the properties of an interval scale together with a fixed
heavy as that of 30 kg
The highest level of measurement is a ratio scale
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MeasurementLevels/Scales
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Example
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Example
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Example
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Measure of morbidity
Used to describe the presence of disease in a population, or
the probability of its occurrence
There are two general types of measures of disease
frequency, incidence (I) and prevalence (P)
Incidence measures new cases of a disease that develop
over a period of time where as
Prevalence measures existing cases of a disease at a
particular point in time or over a period of time
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Types of Incidence
Two types of measures of incidence defined by the type of
denominator
1. Incidence based on person at risk
2. Incidence based on person-time units at risk
The Cumulative incidence rate and incidence density or
incidence rate or person-time rate
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Cumulative incidence.
In epidemiologic studies observation on all study units is
not possible-censored observation
Lost to follow up
Death from causes other than the outcome of interest
Different recruitment time/may not develop event of
interest when the study ends.due to shorter period/
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person-time units
The numerator of the incidence density is the number of new
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Period prevalence
Requires the assumption of a stable dynamic population for
estimation
Helps to know how much of a particular disease is present in a
population over a longer period
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survival
despite
incidence
unchanged
or
even
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Measures of morbidity
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Measures of morbidity
Prevalence rate is directly proportional to both incidence rate
and to the average duration of the disease and thus
expressed as
P ~ IR x D
If incidence is high but duration is short, prevalence is
low
If incidence is low but duration is long, prevalence is
high
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Measures of morbidity
Uses of Prevalence and Incidence
Prediction of future illness
Incidence - Need to assess causation
Clinical decision making
Prevalence useful in guiding diagnostic and treatment
decisions
Comparisons of health states
Both useful
Compare proportion of population with one disease vs.
another (prevalence)
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Measures of morbidity
Prevalence may be more useful when
Onset of health state not clear
Population at risk difficult/impossible to ascertain
Planning for health resources and facilities
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Measures of morbidity
Limitations of prevalence studies
Prevalence studies favor inclusion of chronic over acute
cases
Disease status and attribute are measured at the same
time; hence, temporal relations cannot be established
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Measures of morbidity
Example
Two surveys were done in the same community 12 months
apart. Of 10,000 people surveyed the first time, 50 had
antibodies to histoplasmosis. Twelve months later, 70 had
antibodies, including the original 50. Calculate
A. The prevalence at the second survey,
B. Compare the prevalence with the 1-yr incidence &
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Measures of morbidity
Answers
A. Prevalence at the second survey:
X = antibody positive at second survey = 70
y = population = 10,000
(X/y) X 10n = 70/10,000 x 1,000 = 7 per 1,000
B. Incidence during the 12-month period:
X = number of new positives during the 12-month period =
70 - 50 = 20
y = population at risk = 10,000 - 50 = 9,950
(X/y) X 10n = 20/9,950 x 1,000 = 4 per 1,000
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Measures of morbidity
Attack Rate
An attack rate is a variant of an incidence rate, applied to a
narrowly defined population observed for a limited time,
such as during an epidemic
The attack rate is usually expressed as a percent, so 10 n
equals 100
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Measures of morbidity
Example
Of 75 persons who attended a School picnic, 46
subsequently developed gastroenteritis
To calculate the attack rate of gastroenteritis we first define
the numerator and denominator:
AR=
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Measures of morbidity
Secondary Attack Rate
It is a measure of the frequency of new cases of a disease
among the contacts of known cases
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Measures of morbidity
Example
Seven cases of hepatitis A occurred among 70 children
attending a child care center. Each infected child came from a
different family. The total number of persons in the 7 affected
families was 32. One incubation period later, 5 family
members of the 7 infected children also developed hepatitis
A. Calculate the attack rate in the child care center and the
secondary attack rate among family contacts of those cases
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Measures of morbidity
Answers
1. Attack rate in child care center:
x = cases of hepatitis A among children in child care center
=7
y = number of children enrolled in the child care center =
70
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Measures of morbidity
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Measurements of Mortality
A mortality rate is a measure of the frequency of occurrence of
death in a defined population
Rates whose denominators are the total population are
commonly calculated using either
The mid - interval population or
The average populationpopulation size fluctuates
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Measurements of Mortality
1. Crude mortality rate (crude death rate):
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Measurements of Mortality
4. Sex-specific mortality rate
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Measurements of Mortality
7. Post-neonatal mortality rate
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Measurements of Mortality
10. Child mortality rate
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Measurements of Mortality
13. Maternal mortality rate
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Measurements of Mortality
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Measurements of Mortality
Years of Potential Life Lost and YPLL Rate
Is a measure of the impact of premature mortality on a
population (death occurred before average life expectancy)
It is calculated as the sum of the differences between some
predetermined end point and the ages of death for those who
died before that end point
The two most commonly used end points are age 65 years
and average life expectancy
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Measurements of Mortality
Calculating YPLL from a frequency distribution
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Measurements of Mortality
The Years of Potential Life Lost Rate
It represents years of potential life lost per 1,000
populations below the age of 65 years (or below the
average life expectancy).
Used
to
compare
premature
mortality
in
different
populations
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Measurements of Mortality
Example
Using the motor vehicle injury (MVI) data in Table below, we
will calculate the following:
a. MVI related mortality rate, all ages
b. MVI related mortality rate for persons under age 65 yrs
c. MVI related years of potential life lost
d. MVI related YPLL rate
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Measurements of Mortality
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Measurements of Mortality
Answers
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Measurements of Mortality
c. MVI-related years of potential life lost
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Measurements of Mortality
c. MVI-related years of potential life lost
3. Calculate age-specific YPLL by multiplying the number of deaths in a
given age group by its years of potential life lost
For the age group 0 to 4 years, 1190 deaths x62.5 equals 74,375.0
years of potential life lost
4. Total the age-specific years of potential life lostSum the age specific
YPLL
The total years of potential life lost attributed to MVI in country x in 1997
was 1,441,985 yearssee table below
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Measurements of Mortality
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Measurements of Mortality
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Measures of association
We use measures of strength when we would like to
compare the strength of association between exposed and
unexposed subjects
We use
Incidence rates in prospective studies
Prevalence rates in cross-sectional studies to see the
strength
of
association
between
exposed
and
unexposed individuals
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measures of associations
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Measures of Association
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Measures of Association
Risk Ratio or Relative Risk
Compares the risk of a health event (disease, injury, risk
factor, or death) among one group with the risk among
another group
It indicates the likelihood of developing the disease in
exposed group relative to those who are not exposed
It is the ratio of the risk for one group, say group 1, to the risk
for another group, say group 0
This is the measure of association mostly used in cohort
studies
Its value can be <1, >1, or = 1
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Measures of Association
Referring the prototype two-by-two table presented above
Risk in exposed = a/a+b
Risk in non-exposed = c/c+d
Therefore, RR = a/ a+b
c/ c+d
If the RR >1, there is an association between exposure and
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Measures of Association
If the RR<1, there is an association between exposure and
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Measures of Association
In general the strength of association can be considered:
High - if the RR is 3.0 or more
Moderate if the RR is from 1.5 to 2.9
Weak if the RR is from 1.2 to 1.4
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Cohort study
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Cohort.
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15-20
21-25
26-30
>=31
No of
students
with STI
5
5
5
5
No of
students
with no STI
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20
10
5
Total
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25
15
10
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Measures of Association
Odds Ratio (OR)
The word "odds" means the chances of an event to happen
The Odds of an event is the ratio of the event to happen
over the event not to happen
Odds = Number with events
Number without events
The odds ratio (OR) is the ratio of two odds i.e.
The ratio of the odds in the exposed over the odds in the
non exposed is called the Odds Ratio
Is the measure of association in case control/Crosssectional designs
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Measures of Association
From the above 2x2 table,
OR = a/c
= ad
b/d
bc
The context of OR <1, >1 or = 1 is similar as RR
Interpretation: OR=5 means The odds of outcome among
exposed is 5 times more than non exposed
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When OR~RR
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Measures of Association
Exercise : calculate RR and OR and interpret
the results
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2949
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RR=1
association
between
exposure
and
disease
(more
(more
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