MEASUREMENTS OF

MORBIDITY AND MORTALITY

IN A POPULATION & SOURCE
OF ERROR

SAWITRI
 GOAL
Demonstrate ability to search, collect, organize and
interpret information/data from different sources in
order to assist in diagnostic, therapeutic and health

OBJECTIVE
• Differentiate proportion, ratio, rate, prevalence and incidence.
• Explain four types of incidence based on their denominators.
• Describe the source of numerators and denominators for
prevalence and incidence.
• Explain types of errors in rate calculation.
 CONTENT
• Introduction
• Type of measurements
• More on Incidence and Prevalence
• Specific measurements
• Sumary
Introduction
 Doctor and Patient
Diagnose
Tr e a t / t h e r a p y
Determine the prognosis

http://www.google.co.id/imgres?imgurl=http://us.123rf.com/40
0wm/400/400/justmeyo/justmeyo1010/justmeyo101000384/8
042129-doctor-woman-having-conversation-with-elderly-
patient-in-office-and-preparing-to-write-prescription.jpg

BEHAVIOR

http://www.google.co.id/imgres?imgurl=http://carolynandersonmd.com/
wp-content/uploads/2010/05/doctor-connecting-patient.jpg
 Doctor and Community
Community

Family

Genetic

Behavior

Environment
Individual

Health Facilities
Development from healthy in to illness based on severity
of illness in the population setting

Total
Population

Illness

Seeking treatment

Hospitalized
Death
 Natural History and Source of Data

Outcome:
Cure
Healthy
Control
Disability
Disease Symptoms Seek care Diagnosis Treatment
Onset Death

Survey & Interview in community setting

Data Doctor/Clinic Record

Sources
Hospital Record
TYPES OF MEASUREMENT
 JENIS UKURAN
• ANGKA ABSOLUT
• ANGKA RELATIF
– RATIO
– PROPORSI
– RATE  INSIDEN, PREVALEN
Absolute Number

NUMERATOR

FSWs are classified mostly as direct (those who work in brothels and
street‐based sex workers) or indirect (such as women working in
karaoke bars or massage parlors). It is estimated that there are
95,000-157,000 direct sex workers and 85,000-107,000 indirect sex
workers as of 2009. In 2006, the figure was put at 221,000 women
working in the sex industry, serving an estimated 4 million clients per
year [Sex Work and HIV in Indonesia, 2011].
DISTRIBUTION OF PERSONS BITEN BY DOGS PER SUB-
VILLAGES AT UNGASAN

No Name of Sub-villages Total Description

1. Giri Darma 15 Death = 2 persons
2. Santi Karya 2
3. Bakung Sari 4 Death = 1 person
4. Sari Karya 7
5. Wijaya Kesuma 2 Death = 1 person
6. Wana Giri 1
7. Dusun Kauh 1
8. Dusun Kelod 8
9. Dusun Kangin 10
10 Santi Karya 3
11. Jaba Pura 0
12 Kaja Jati 0
13 Petangan 0
Jumlah 53 Total deaths 4 persons
 Relative Number

NUMERATOR

n=
DENOMINATOR
 Ratio
• Numerator and Denominator are
independent
• Example
– Dependency Ratio
– Sex Ratio
n=
 Proportion
• Numerator is part of denominator

n=
Cumulative HIV Cases Per District
In Bali, 1987 - 2011

52
1059
78
138
301

213
81

2179

732

Bali Provincial Health Dept,

Sept 2011
 Cumulative HIV Cases Per District
In Bali, 1987 - 2011

52
6% 1059
2% 15%
3% 78
2% 138
301Badung
4% 1% Bangli
Buleleng
Denpasar 213
81
Gianyar
22%
Jembrana
2179
Karangasem
732
Klungkung
Tabanan
45% Bali Provincial Health Dept,
Sept 2011
 RATE
• A proportion when the denominator is a
population at risk

n=
population at risk!
MORE ON INCIDENCE
AND PREVALENCE
 INCIDENCE
• Proportion of population that not having illness
previously and then become ill during the
certain period among observed at risk
population

• NEW CASES
• RISK OF BEING ILL
 CONDITION
Numerator / Denominator, Constant, Period
1 2 5 4 3

1. Similar characteristics of N & D

2. Denominator is a “population at risk”
3. During a period of time [time frame]
4. Constant of round number of 10 fold
5. Denominator is a population of certain
geographic area
 Cumulative Rabies Cases Per District
In Bali, 2008 - 2011
Total Population:
3,891,428 persons
26  6 
0
 36
18 
7
# of new cases 2012 = 5 2
1 in Denpasar
2 in Karangasem 8
2 in Badung
1
11
Incidence rate Bali (2012)
2
= (N/pop at risk)*Constant  21
= ……..?
Bali Provincial Health Dept, 2011
 RABIES IN BALI, 2008-12
Kabupaten Frek Total Population Proportion Incidence Rate
Jembrana 0 272.828 0
Buleleng 26 662.920 19.5
Tabanan 18 431.172 13.5
Badung 21 (+ 2) 393.020 15.8
Denpasar 11 (+ 1) 523.299 8.3
Gianyar 7 399.660 5.3
Klungkung 8 185.272 6.0
Bangli 6 215.729 4.5
Karangasem 36 (+ 2) 438.475 27.1
Total 133 3.522.375 100.0

Bali Provincial Health Dept, 2011

Natural History of Diseases and Source of Data

Outcome:
Healthy Cure
Control
Disability
Disease Symptoms Seek care Diagnosis Treatment
Onset Death

Survey and Interview

Source of
Data Record of doctor/clinic

Hospital Medical Record

 Calculating Incidence
• Direct method  Primary Data
– Interview
– Measurement/Assessment

• From Secondary Data

– Numerator  records (GP/Clinics/hospital/public
health center
– Statistic office, estimation from census, census

• Estimating from prevalence

Important Notes!!
• Incidence of persons or events?
• Denominator of Incidence?
– “population at risk?” (death, drop out, immune, lost
to follow up)
– Availability of data, particularly for the denominator
(mid-year, average, beginning plus end divide by 2,
etc)
– Person years (person time)  Incidence density,
cumulative incidence
 PREVALENCE

• Proportion of population who suffer for

illness at the time of measurement among
the observed at risk population.

• NEW and OLD CASES

• NOT DESCRIBE AT RISK
 Type of prevalence
• Point prevalence
– New and old cases at the point of time
measurement

• Period prevalen
– New and old cases at the beginning of
measurement added by new cases on the
whole period of measurement
 BAGAN
Period prevalen

New Cases

Point prevalen
 Cumulative Rabies Cases Per District
Bali, 2008 - 2011
Total Population:
3,891,428 persons
26  6 
0
 36
18 
7
# of new cases 2012 = 5 2
1 in Denpasar
2 in Karangasem 8
2 in Badung
1
11
Prevalence at 2008-2011?
2
 21

Bali Provincial Health Dept, 2011

 RABIES IN BALI, 2008-11
Kabupaten Frek Total Population Proportion Prevalence Rate
Jembrana 0 272.828 0
Buleleng 26 662.920 19.5
Tabanan 18 431.172 13.5
Badung 21 393.020 15.8
Denpasar 11 523.299 8.3
Gianyar 7 399.660 5.3
Klungkung 8 185.272 6.0
Bangli 6 215.729 4.5
Karangasem 36 438.475 27.1
Total 133 3.522.375 100.0

Bali Provincial Health Dept, 2011

Relationship between prevalence and incidence

WHEN (the steady state is in effect):

a) Incidence rate (I) has been constant over time

b) The duration of disease (D) has been constant
over time:
ID = P / (1 – P)
P = ID / (1 + ID)
c) If the prevalence of disease is low (i.e. < 0.10):

P = ID .
 Discuss in your group!

How is the relationship between

incidence and prevalence?
SPECIFIC MEASUREMENT
Case Fatality Rate # of Deaths from a Disease
# of Cases from that Disease

Survival Rate # of survivors from a Disease

# of Cases from that Disease

Attack Rate # of Cases of a Disease

Total Population at Risk for
a Limited Period of Time
Infant Mortality Ratio?

Maternal Mortality Ratio?

Maternal Mortality Rate?

Crude Death Rate?

Crude Birth Rate?

 COMPARISON BETWEEN INCIDENCE AND
PREVALENCE

Incidence Prevalence

Risk to suffer for Proportion of suffering

disease (period of time) disease (point of time)

For acute/chronic For cronic

Application:
Application:
- Etiology
- Manajemen
- Managemen
SUMARY
• 4 Types of Measurements
• Each measurement have:
• Characteristic
• Meaning/Interpretation
• Purpose
• Weakness/advantages
• Understanding measurements will help
doctor either as clinician or PH workers to do
their job properly