Department of Community Medicine (SPM) Government Medical

College, Srinagar

Epidemiology Learning Module

For MBBS Students

NAME: __________________________________________________________________

ROLL NUMBER: ________________ BATCH (MBBS): _________________

1
Objectives of the Module

To develop a basic understanding of the principles of epidemiology, biostatistics, and research among
undergraduate medical students and enable them to use the concept to conduct health research and practice
evidence-based medicine and public health.

2
Instructions for students

i) Should attend all the sessions and report on time.

ii) Should come prepared for sessions as instructed by the tutor.
iii) Should strictly follow the ground rules for small group sessions as agreed upon.
iv) Should not hesitate to raise queries and ask questions.
v) Should provide constructive feedback to improve the module in the future.

3
Contents

1. Measures of frequency: Ratio, Rate, and Proportion

2. Morbidity rates and ratios

3. Mortality rates and ratios

4. Standardized rates

5. Descriptive epidemiology

6. Epidemics

7. Cohort study

8. Case-control study

9. Randomized Controlled Trials

10. Investigation of an epidemic

11. Screening

12. Association and Causation

13. Research project

4
 Measures of frequency: Ratio, Rate, and Proportion
Learning objectives
By the end of the session students should be able to:
1. Differentiate between ratio, rate, and proportion with the help of suitable examples.
2. Describe the properties and application of these measures in public health.
Reading material
The occurrence of any health-related event in a population is usually measured by quantifying them. The
foundation of epidemiology lies in accurately measuring morbidity and mortality. This provides a basis for
monitoring disease trends, evaluating public health interventions, and assessing other interventions aimed
at improving population health. The epidemiological measures used to describe occurrence of disease,
death, or disability in a population are described as ratios, rates and proportions. They are used to compare
one part of distribution of data to other part of distribution or to entire distribution. All these measures
share common characteristics: a numerator, a denominator, and a multiplier. The multiplier is determined
by the type of frequency measure being addressed.
Numerator
×10n
Denominator

Ratio: A ratio is the relative magnitude of two quantities or a comparison of any two values. The
numerator and denominator need not be related. In certain situations, the numerator and the denominator
can be different categories of the same variable (ratio of males 40-50 years to males 60-70 years of age), or
an entirely different variable (ratio of number of students with refractive error to the total doctor
population of a district).
Number of events in one group
Ratio=
Number of events in another group

Properties of a ratio:
Ratios are used both as a descriptive and analytical measure in epidemiology.
1. As a descriptive measure, ratios can describe the doctor-to-population ratio or the ratio of controls to
cases (e.g., two controls per case).
2. As an analytic tool, ratios can be used to compare the occurrence of illness, injury, or death between
two groups. These ratio measures include risk ratio, rate ratio, and odds ratio.
3. Sex ratio refers to the number of females per 1000 males. It is an important demographic indicator.
In India, sex ratio was 972:1000 in 1901; 933:1000 in 2001, and 940:1000 in 2011 indicating more males
than females. Declining sex ratio in India has been linked to female foeticide due to preference for male
child.

Proportion: It is a type of ratio in which the numerator is part of the denominator. It is often expressed

5
as percentage. It is a useful and informative frequency measure often used to express the amount of disease
attributed to a specific cause or risk factor. For example, lack of portable drinking water is responsible for
60% of diarrheal diseases among children in India. A specific type of proportion is proportionate
mortality.
Number of events in a population
×100
Total population in which the event occurred

Properties of a proportion:
1. Proportions are the most used descriptive measure in epidemiology. For example, participation rate is
often used in epidemiological studies to describe the proportion of participants who got enrolled in a study
among all those who were eligible. Similarly, non-response rate reflects the number of individuals who did
not agree to participate in a study due to various reasons when they were approached to be part of a study.
2. Proportion is frequently used to express the amount of disease that can be attributed to a risk factor.
For example, 40% of infant mortality in India is due to prematurity. In other words, it also reflects the
scope of reduction measures in alleviating a particular health problem in a population.
3. Proportionate mortality is the proportion of deaths in a specified population during a period of time
that are attributable to different causes. Each cause is expressed as a percentage of all deaths, and the sum
of the causes adds up to 100%. These proportions are not rates, because the denominator is all deaths and
not the size of the population in which the deaths occurred. For example, cardiovascular diseases are
responsible for 20% of all deaths in India. Here, the denominator is all deaths, and the numerator is the
contribution of each cause leading to death.
Number of deaths due to a particular cause
Proportionate mortality= ×100
Total number of deaths from all causes

Rate: Rate is a measure of the frequency with which an event occurs in a defined population over a
specified period of time. Because rates put disease frequency in the perspective of the size of the population,
rates are particularly useful for comparing disease frequency in different locations, at different times, or
among different groups of persons with potentially different sized populations; that is, a rate is a measure
of risk.
A rate is a measure that is reported per unit of time. For instance, it is commonly used to describe the speed
at which a disease occurs in a population. An example of a rate is 70 new cases of breast cancer per 1,000
women per year, which expresses the frequency of occurrence of the disease over a specific period. By
measuring rates over time, epidemiologists can track disease trends and assess the impact of interventions
aimed at reducing disease incidence and prevalence.

6
Exercises

1. For each of the fractions shown below, indicate whether it is a ratio, a proportion, or a rate
and discuss.

Number of women who died from heart disease in Kashmir in 2022

a. Number of women who died in Kashmir in 2022

Number of women who died from heart disease in Kashmir in 2022

b. Estimated number of women living in Kashmir on July 1, 2022

Number of women in Ladakh who died from heart disease in 2022

c. Number of women in Ladakh who died from cancer in 2022

Number of women in Jammu who died from lung cancer in 2022

d. Number of women in Jammu who died from cancer (all types) in 2022

Number of women in Jammu who died from lung cancer in 2022

e. Estimated revenue (in INR) from cigarette sales in 2022

Number of women newly diagnosed with heart disease in Kashmir in 2022

f. Estimated number of women living in Kashmir on July 1, 2022

7
Morbidity rates and ratios

Learning objectives
At the end of the session the students should be able to:
1. Describe frequently used measures of morbidity including incidence proportion, incidence rate, and
prevalence.
2. Discuss risk, attack rate, and secondary attack rate.
3. Calculate and interpret measures of morbidity with the help of examples.

Reading material
Morbidity is defined as any departure, subjective or objective, from a state of physiological or psychological
wellbeing. It includes the presence of disease, injury, and disability. Most frequently used measures of
morbidity are tabulated below (Table 1).

Table 1: Measures of Morbidity

Measure of morbidity Numerator Denominator

Incidence proportion (or attack Number of new cases of disease Population at start of time
rate or risk) during specified time interval interval

Secondary attack rate Number of new cases among Total number of contacts
contacts

Incidence density (or person- Number of new cases of disease Summed person-years of
time rate) during specified time interval observation

Incidence rate Number of new cases of disease Average population during the
during specified time interval time interval

Point prevalence (or prevalence) Number of current cases (new andPopulation at the same specified
pre-existing) at a specified point in point in time
time

There are three ways of describing the incidence of a disease. They include:

1. Incidence proportion,
2. Incidence density/person-year rate, and
3. Incidence rate.
1. Incidence proportion: also known as risk, attack rate, cumulative incidence, and probability of
developing disease. It is defined as the number of persons who become ill during a given period in a
specified population. This type of incidence is a proportion as the number of people who become ill in a
specified population in a specified period are all included in the denominator.
Number of new cases of disease
Incidence proportion=
Size of population at the start of study

8
Consider a hypothetical example of a class of 50 medical students from October 2022 to December 2022
(Fig1). An epidemiologist is interested in measuring the cumulative incidence of first episode of upper
respiratory infection (fever and sore throat) during this period. The timeline of outcome (upper respiratory
tract infection) among the students is given below. It was observed that 10 students developed the outcome
at different intervals during this period (October to December). In addition, five students migrated to
other colleges.

Fig1: Hypothetical example of incidence of acute respiratory infection in medical students

10 new cases
Cumulative incidence= =0.2=20% during Oct-Dec 2022
50 at risk
The above example represents the proportion of students that develop ARI during a fixed period.
Several key points emerge from this example. Firstly, the cumulative incidence does not consider dropouts
(loss to follow-up); the denominator is the number of students enrolled at the beginning of the period
(October). Secondly, cumulative incidence does not consider the "time at risk" (when did a student develop
ARI) or when they dropped out. Last but not least; cumulative incidence is a proportion that provides an
estimate of the risk of developing disease, not the rate.
Some other properties of incidence proportion:
1. The numerator includes only new cases of disease in the numerator and the denominator is the number
of persons in the population at the start of the observation period.
2. Incidence proportion is a measure of the risk of a specified health-related event. In other words, it gives
a risk of developing an event in a specified period.
3. Attack rate is synonymously used for incidence proportion in outbreaks. It gives us the risk of getting
disease in an outbreak till the time it lasts.
4. Food-specific attack rate: A special type of attack rate which is calculated as the number of persons who
ate a specified food and became ill divided by the total number of persons who ate that food. For example:

Number of person who consumed fruit salad and got sick

×100
Total number of people who consumed fruit salad

9
Secondary attack rate: Secondary attack rate is the measure of transmission of infection in a closed
population like a household, school, hostel, or cruise. Secondary attack rate is defined as the number of
cases of an infection that occur among contacts within the incubation period following exposure to a
primary case. The denominator is restricted to susceptible contacts only.
In a hypothetical example of the spread of chickenpox in a play school with 20 children, it is presumed
that the infection resulted from a child who had exposure outside the school. Five secondary cases occurred
approximately five days after symptoms were observed in the index child. Upon further investigation of
vaccination history, it was revealed that three children had already been vaccinated against chickenpox at
the age of one year. Thus, the secondary attack rate among the play school contacts was [5/ (20 −3-1)] ×
100 = 31.2%.
Number of cases among contacts of primary cases
Secondary attack rate= ×100
Total number of contacts
2. Incidence density: It describes the rate of development of a disease in a population over a certain period
and this period is included in the denominator. An incidence rate includes three important elements:
1. a numerator: the number of new cases
2. a denominator: the population at risk
3. time: the period during which cases occur
Akin to the incidence proportion, the numerator of the incidence rate represents the number of new cases
of a disease/event identified during the period of observation. However, the denominator is the sum of the
time each person was observed, totalled for all persons. In other words, denominator represents the total
time the population was at risk of and being watched for disease.
Number of new events⁄cases of a disease during a specified period
Incidence density= ×10n
Time each person was observed, totalled for all persons
This type of incidence rate is also known as person-time rate. A person-time rate is generally calculated
from a cohort study, wherein participants are followed over time and the occurrence of new cases of disease
is documented. Each person is observed from an established starting time until one of four “end points” is
reached: onset of disease, death, loss to follow-up, or the end of the study. When a person is followed for
a period of one year before he achieves the end point, he contributes one person-year to the denominator.
Similarly, ten persons followed for one year without developing disease contribute ten person-years. So,
the denominator for person-time rate or incidence density is the sum of person-years of each participant
during which they remain event free.

Some other points to consider:

1. Incidence density is an important frequency measure used in cohort study design. Since person-time
is calculated for each subject, it can accommodate persons coming into and leaving the study at any time
point. The denominator accounts for study participants who are lost to follow-up or who die during the
study period.
2. Students might often find it difficult to understand the expression of person-time rate. If you are
reporting the incidence rate of breast cancer as 2.5 per 1,000 person-years, simply replace “person-years”
with “persons per year”. Reporting the results as 2.5 new cases of breast cancer per 1,000 persons per year
conveys the sense of the incidence rate as a dynamic process, the speed at which new cases of disease occur
in the population.

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Example:

Fig 2 depicts a hypothetical cohort in which five subjects were followed for 6 years for diabetes (outcome
of interest). None of them had diabetes mellitus at the beginning of the study, and all of them were enrolled
in Jan 2010. All subjects were contacted yearly and none of these subjects developed the health outcome
of interest at any time during the study, and none were lost to follow-up. Therefore, each of the five subjects
contributed 6 years of disease-free observation time during which they were "at risk". In this example, the
concept of "person-time" is simple; the total person-time for the group is 30 years, because there were 5
subjects, and each of them was followed completely for 6 years without developing diabetes which was an
outcome of interest for the researchers (Fig 2).

Fig 2: A hypothetical cohort followed for 6 years

Now let us consider one more example of a cohort consisting of 10 women depicted in Fig 3 below. None
of the subjects had the disease of interest (breast cancer) at the beginning of the study. The subjects were
enrolled in 2000 and followed up to 2014. Subjects 2, 5, and 10 developed breast cancer after 6, 10 and 8
years of observation respectively. In addition, two subjects were lost to follow-up at different times, and
five subjects (1, 3, 6, 7, 9) remained disease free all the way to 2014 when the study ended (Fig 3). The
sum of the years "at risk" of these 10 women is 108 person-years, and there were 3 occurrences of disease.
We can now compute the incidence rate:

Number of new cases during observation period

Incidence Rate= Total person-time of observation while at risk during study

3
In this example, Incidence Rate= 108 =0.0277 cases of breast cancer per person-year
Time is an inherent part of the calculated incidence rate, but one should still state the time period over
which it was calculated, e.g., "The incidence rate was 2.77 per 100 person-years from 2000 to 2014”, or
“27.7 per 1000 person-years from 2000 to 2014”.
3. Incidence rate : This type of incidence rate uses a numerator based on the number of cases observed or
reported, and a denominator based on the mid-year population. This type of incident rate is comparable
to a person-time rate.
Example: In 2017, 10,322 new cases of tuberculosis were reported in Kashmir. The estimated mid-year
population of Kashmir was approximately 4.45 million. Calculate the incidence rate of tuberculosis in
2017.
Numerator = 10,322 new cases of tuberculosis; Denominator = estimated mid-year population = 4.45
million; 10n =100,000
Incidence rate = (10,322 Ú 4,450,000) × 100,000 = 232 new cases of tuberculosis per 100,000 population.

11
 10

py

2012
2010
2000

2008
2002

2004

2014
2006

Fig 3: Hypothetical cohort of 10 breast cancer women followed for ten years
( = Disease, = Loss to follow-up)

Table 2: Strengths and limitations of Cumulative Incidence & Incidence density

Cumulative Incidence Incidence density

Strengths Easily calculated and understood since Takes into account losses to follow-
it measures risk up and when disease occurs
Limitation Does not take into account losses to Need individual follow-up, which is
follow-up or when disease occurs costly and time-consuming
Appropriate use Fixed populations with short follow-up, - Dynamic populations
or no losses to follow-up - Fixed populations with long
follow-up times, or substantial loss
to follow-up

Prevalence
Prevalence is the proportion of population who have a specified condition at a specified point in time or
over a specified period. Prevalence differs from incidence in that prevalence includes all cases, both new
and pre-existing, in the population at the specified time, whereas incidence is limited to new cases only.
All new and pre-existing cases during a given time period n
Prevalence = x 10
Population during the same time period
Properties and uses of prevalence
1. It is very important to understand the key difference between incidence and prevalence estimates.
The basic difference lies in their numerator.
2. In case of incidence, numerator includes only those persons whose illness began during the
specified interval whereas for prevalence it includes all persons ill from a specified cause during the specified

12
interval regardless of when the illness began. In addition to new cases, it includes preexisting cases that
represent persons who remained ill during some portion of the specified interval.
3. Prevalence is based on both incidence and duration of illness. High prevalence of a disease within
a population might reflect high incidence or prolonged survival without cure or both. Conversely, low
prevalence might indicate low incidence, a rapidly fatal process, or rapid recovery.
4. Prevalence is often measured for chronic diseases such as diabetes or osteoarthritis which have long
duration and dates of onset that are difficult to pinpoint.

Example:

In 2015, it was estimated that there were 1,00,000 people with diabetes in Srinagar. The population of
Srinagar in 2015 was about 12 lakhs.

100000
Prevalence= × 100 = 8.33% in 2015
1200000

The above figure can also be written as 83.3 per 1000 people in 2015.

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Exercises

1. Identify the type of incidence and prevalence.

Number of newly diagnosed women with breast cancer in Kashmir in 2015

a.
Estimated number of women living in Kashmir on July 1, 2015

Number of women in Framingham study newly diagnosed with heart disease last year
b.
Number of women in Framingham study without heart disease at the beginning of same year

Number of women enrolled in a cohort who have died through last year from breast cancer
c.
Number of person-years contributed through last year by women initially enrolled in the study

Number of children who have defective vision as diagnosed on 15th September, 2018
d.
Number of children screened on same date

Estimated number of males newly diagnosed with heart disease in Kashmir in 2016
e.
Estimated number of males living in Kashmir on July 1, 2016

Number of men in Srinagar who reported to have diabetes mellitus (old and new) in a health survey in 2015
f.
Estimated number of men residents of Srinagar during the same period

2. In a survey of 1150 women who gave birth in Nishat area in 2017, a total of 468 reported taking a
multivitamin at least four times a week during the month before becoming pregnant. Calculate the
prevalence of frequent multivitamin use in this group.

3. In 2015, 86,000 new cases of acquired immunodeficiency syndrome (AIDS) were reported in India.
The estimated mid-year population of India in 2015 was approximately 1,210,854,977. Calculate the
incidence rate of AIDS in India in 2015.

4. A study was done to find out the relationship between cigarette smoking and stroke in a cohort of
118,539. Calculate incidence proportion for the total cohort and incidence density for the total cohort
and each smoking category. Interpret your results.
Smoking category Number of Person-years of Stroke incidence rate per 100,000
cases of stroke observation (8 person-years
years)
Never smoked 70 395,594
Ex-smoker 65 232,712
Smoker 139 280,141
Total 274 908,447

5. In an outbreak of gastroenteritis among attendees of a corporate picnic, 99 persons ate potato salad, 30
of whom developed gastroenteritis. Calculate the risk of illness among persons who ate potato salad. Which
type of rate is this?

14
6. Ten cases of flu occurred among 90 children attending a childcare center. Each infected child came
from a different family. The total number of persons in the 10 affected families was 44. One incubation
period later, 15 family members of the 10 infected children also developed flu. Calculate the attack rate
in the childcare center and the secondary attack rate among family contacts of those cases.

7. The figure below represents hypothetical data from a cohort study in which 10 healthy women were
recruited from 2004 to 2018 and were followed for the development of breast cancer.

Calculate:
a. Total person years of follow-up.
b. Incidence rate (density) of breast cancer in the population.
c. Prevalence of breast cancer in 2012.
d. Cumulative incidence of breast cancer in the cohort.

15
8: The table shows the total number of persons who became sick after eating egg salad.
Item Consumed Sick Total
Ate egg salad 75 200
Did not eat egg salad 80 220

What are the attack rates in persons who ate egg salad and those who did not eat egg salad?

9: After a dinner attended by 100 people, 12 individuals become ill. All 100 people are interviewed about
their food consumption at the dinner. The interviews shows that 8 of the 12 people who are ill and 25 of
the 88 who are healthy ate fish. What are the attack rates in persons who ate fish and those who did not
eat fish?

Total Number of Persons Who Ate Each Specified Combination of Food Items and Who Later
Became Sick
Item Consumed Ill Well

Ate fish 8 25
Did not eat fish 4 63
TOTAL 12 88

10: Many of the students at a boarding school, including 6 just coming down with varicella, went home
during the Eid break. About two weeks later, 4 siblings of these 6 students (out of a total of 10 siblings)
developed varicella. Calculate the secondary attack rate of varicella among the siblings.

11: Seven cases of Hepatitis A occurred among 70 children attending a childcare centre. 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 secondary attack rate among family contacts of those cases.

16
 Mortality rates and ratio
Learning objectives
At the end of the session the students should be able to:

1. Describe various mortality rates and ratios (crude death rate, specific death rate, proportionate
mortality ratio).
2. Calculate and interpret mortality rates and ratios.

Trigger/Scenario
In 2009, a strain of Influenza A(H1N1) virus which had not been seen before, emerged in USA, and spread
across the world and caused the 2009 H1N1 pandemic. A pandemic occurs when an influenza virus, which was
not previously circulating among humans and to which most people have no immunity, emerges and transmits
among humans. These viruses may emerge, circulate, and cause large outbreaks beyond influenza season. As
most of the population has no immunity, the number of people infected may be quite large. Some pandemics
may result in large numbers of severe infections while others will result in large numbers of milder infections.
What quantitative measures enable public health professionals to decide that the pandemic has occurred?
How many deaths are occurring due to the virulent strain? How fast is the virus spreading in a population?
Which age group or gender is affected more?
How do public health interventions impact the containment of the virus?

Mortality rate
It is a measure of the frequency of occurrence of death in a defined population during a specified interval. It
is calculated as:
Deaths occurring during a given time period
Mortality rate= × 10
Size of the population in which deaths occurred
The denominator most commonly used is the size of the population in the middle of the time period. As
population changes over time, midyear population is taken as an approximation of the average population.
Commonly used mortality measures are tabulated below (Table 3):

Table 3: Mortality Rates

Mortality rate Numerator Denominator Multiplier
Crude death rate Total number of deaths Mid-interval population 1000
during a given time interval

Cause-specific death rate Number of deaths assigned Mid-interval population 1000

to a specific cause during a
given time
interval

17
 Mortality rate Numerator Denominator Multiplier
Proportionate mortality Number of deaths assigned Total number of deaths 100
to a specific cause during a from all causes during the
given time interval same time interval

Age-specific death rate Number of deaths in a Total number of people in 1000

specific age group that age group in the
population
Sex-specific death rate Number of deaths in a Total number of people of 1000
specific gender that gender in the
population
Combination of mortality Number of deaths in specific Total number of people of 1000
rate e.g., Age and sex gender and specific age that gender in the specified
specific mortality rate group age group

Case fatality Number of deaths due to Total number of cases of 100

particular disease that particular disease

Death-to-case ratio Number of deaths assigned Number of new cases of 100

to a specific cause during a same disease reported
given time interval during the same time
interval

Crude death rate: It is the number of deaths from all causes for a population during a given year. It is an
indirect measure of the health status of the population. It can be used to make crude comparison of mortality
between two or more geographical areas with limitations. However, it does give a fair idea about the health
status of the population by comparing with previous years. For example, the crude death rate of India was
7.1/1000 mid-year population in 2011, 7 ptp (2012), 7 ptp (2013), 6.7 ptp (2014), 6.5 ptp (2015), and 6.4
ptp (2016), and thus have shown a declining trend. (ptp- per thousand population).
Cause-specific or disease-specific mortality rate: The cause-specific mortality rate is the mortality rate from
a specified cause for a population. For example, deaths due to breast cancer can be calculated as:
Number of deaths from breast cancer in one year
Annual mortality from breast cancer= ×1000
Number of persons in the population at mid-year

Age-specific mortality rate: Sometimes we may be interested to know the mortality experience of a
particular age group. In that situation we can calculate the age-specific mortality rate for that age group. Some
specific types of age-specific mortality rates are neonatal, post-neonatal, and infant mortality rates.
Age-specific mortality rate for children 5-10 years=
Number of deaths from all causes for children 5-10 years
×1000
Number of children in the population of 5-10 years at mid-year

18
Sex-specific mortality rate: A sex-specific mortality rate is a mortality rate among either males or females.
The same restriction is put in the denominator.
Number of deaths from all causes for women
Sex-specific death rate for women= ×1000
Number of women in the population at mid-year

Combinations of specific mortality rates: Mortality rates can be further stratified by combinations
of cause, age, sex, and/or race. For example:
Annual mortality from pneumonia in children under 5 years of age=
Number of deaths from pneumonia in children<5 years of age
×1000
Number of children (<5 years)in the population at mid-year

While calculating mortality rates one has to be specific with respect to -

Denominator: For mortality rate to be meaningful, the denominator must have a potential to become part
of the numerator.
Time: In any mortality rate time must be explicitly mentioned. The selection of time period can be arbitrary
though. It can be calculated over one year, five years, seven years and so on.

Case fatality: A case fatality represents the proportion of individuals who die due to a specific disease
among those who were diagnosed with that disease.
Case fatality (%)=
Number of individuals dying due to a specific disease after onset or diagnosis
×100
Number of individuals with the specific disease
Case fatality is a proportion. It is not a rate as it is not expressed per unit of time. The denominator includes
those who have the disease rather than the population considered at risk of developing the disease. In other
words, it reflects the severity or killing power of the disease. For example, in a population of 10000, ten
people became infected with Ebola virus in one year, of whom eight died. The case fatality rate of Ebola
will be 80%. This reflects the chance of dying from the infection is very high once a person contracts the
infection.
Death to Case Ratio:
Number of deaths attributed to a particular disease during specified period
×10n
Number of new cases of the disease during the specified period
Example: Calculating Death-to-Case Ratio
Q: In India during the year 2021, a total of 4,70,510 incident cases of SARS-CoV-2 were reported. During
the same year, 50,000 deaths were attributed to SARS-CoV-2. Calculate the death-to-case ratio.
Death-to-case ratio = (50000/470510) × 100 = 10.6 per 100 cases.
Some of those who died had developed SARS-CoV-2 infection during December 2020. Thus, some of the
50000 in the numerator are not among the 470510 in the denominator. Therefore, the death-to-case ratio
is a ratio, but not a proportion.

19
Exercises

1. In 2017, the total number of deaths in District Baramulla with a mid-year population of 12.56 lakhs
was 8164. Calculate the crude death rate for the district in 2017.

2. The mid-year population of District Baramulla in the year 2017 was 12.56 lakhs, 6.51 lakh males
and 6.05 lakh females. In the same year, the number of deaths among males in the district was 4284 and the
number of deaths among females was 3880. Calculate:
a) Sex ratio of the district.
b) Specific death rate for males and females.
c) Crude death rate.

3. Consider the given data given below:

Age group Gender Mid-year population Number of

(lakhs) deaths
Male 5.99 1799
<60
Female 5.53 1746
Male 0.52 2485
≥60
Female 0.52 2134
Total 12.56 8164
Calculate:
a) Specific death rate for males ≥ 60 years of age.
b) Specific death rate for females ≥ 60 years of age.
c) Specific death rate for age group ≥ 60 years of age.

4. In District Srinagar with a mid-year population (in 2017) of 15.5 lakhs, the total number of deaths
was 8797. The following is the break-up of these deaths according to the cause of death.
Cause of Death Number of Deaths
Heart diseases 2386
Malignant neoplasms 1953
Cerebrovascular disease 631
COPD 542
Diabetes Mellitus 451
Unintentional injuries 302
All other 2532
All causes 8797

Calculate:

20
a. Specific death rate due to Unintentional injuries.
b. Specific death rate due to Malignant neoplasms.
c. Proportionate mortality rate from
i. Cerebrovascular disease.
ii. COPD.
iii. Diabetes Mellitus.
iv. Heart diseases.

5. Between 2010 and 2019, a total of 2,45,902 cases of influenza were reported. During the same decade,
95,500 deaths were reported and among these 10,000 deaths were attributed to influenza. Calculate the
death-to-case ratio.

6. In Kerala during the period from 8 to 26 July 2021, 590 blood samples were collected and were tested
for Zika virus. Out of these, 70 samples tested positive for Zika virus by RT-PCR. One death was reported
among these. Calculate the Case fatality for Zika Virus disease.

7. The number of tuberculosis cases diagnosed during the year 1990 in an area was 1200. The total
number of deaths in the same area during the same period was 150. Out of these, 30 deaths were attributed
to tuberculosis. Calculate Case fatality for tuberculosis.

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Standardized Rates -
Direct and Indirect Standardization
Learning objectives
At the end of the session the students should be able to:

1. Calculate standardized rates of disease or death for two populations using direct standardization
and interpret the findings in words.
2. Calculate Standardized Mortality Ratio (SMR) for a disease and describe its meaning.

Reading material

Comparing the morbidity and mortality rates of two or more different geographic areas is important for
the evaluation of community health status. It is tempting to compare crude rates. However, comparing
crude rates would be misleading due to the possibility of varying frequency distributions of characteristics that
affect mortality across different populations. Standardization is a statistical method in which the
characteristic(s) responsible for the differences observed in mortality rate are adjusted so that a valid
comparison can be made. Age and sex are two of the most common variables that are adjusted in standardized
rates as they are an important predictor of mortality.

There are two methods for calculating standardized rates, namely direct and indirect.

Direct Standardization: This method provides a useful way to compare health outcomes among
populations that may have different age distributions. This is done by applying a standard age distribution
to the populations being compared to compute hypothetical summary rates indicating how the overall rates
would have compared if the populations had had the same age distribution. This method is used when age-
specific rates of disease are known for the populations being compared.

The concept framework for direct standardisation is given in Fig 4.

Target population(s) – the population(s) that we are interested in. Also known as population of interest.

Standard population – the population that we use to construct comparisons with and between target
populations.

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Procedure for Direct Standardization (Fig 5)

1. Calculate the age-specific mortality rates for each age group in each population.
2. Then choose the standard (reference) population from one of the populations (*Note: If the
mortality rates of a specific community are compared to the national population, then the national
population is considered as the “standard” population).
3. Multiply the age-specific mortality rates of the other population under study to the number of persons
in each age group of the standard population. (This gives the expected deaths for each age group of each
population).
4. Add the number of expected deaths from all age groups.
5. Divide the total number of expected deaths by the standard population to get the age-adjusted mortality
rates.
6. Now, we can compare the age-standardized mortality rates of the two populations.

CDR = Crude Death Rate ADR = Adjusted Death Rate

Summary: Standardization results in "adjusted" rates that are not real, but they have the advantage of enabling
us to compare two or more populations after removing the distorting effect of other confounding factors,
such as age. In many public health circumstances, it is important to compare rates of disease among two or
more populations, but there may be differences in the distributions of the populations that distort the

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comparison. In such situation we use adjusted or standardized rates.
Example

Table 4: Age-group, deaths, and mid-year populations of two different populations

Population A Population B
Age group Mid-year Deaths Age-specific Mid-year Deaths Age-specific
(years) population death rate population death rate
per 1000 per 1000
0-24 18,000 35 1.94 13,000 30 2.31
25-49 11,000 60 5.45 7,000 50 7.14
50-74 9,000 370 41.11 11,000 400 36.36
75 and
3,000 250 83.33 4,000 380 95.00
above
Total 41,000 715 35,000 860
Crude rate
17.44 24.57
per 1000

From the above table we infer that the crude death rates of population B seems to be higher than population
A.

Now, let us consider the national population as the standard population and calculate age- standardized
rates. The calculation will therefore be as follows in Table 5

Table 5: Calculation of expected deaths by applying direct standardization method

Population A Population B
Age group Reference Age-specific death Expected Age-specific death Expected
(years) population rate per 1000 deaths rate per 1000 deaths
0-24 11,000 1.94 21.34 2.31 25.41
25-49 17,000 5.45 92.65 7.14 121.38
50-74 20,000 41.11 822.20 36.36 727.20
75 and
3,000 83.33 249.99 95.00 285.00
above
Total 51,000 1186.18 1158.99
Total number of expected deaths: Population A = 1186.18 Population B = 1158.99

1186.18
Age-adjusted death rate for Population A= ×1000=23.3 per 1000 population
51,000
1159.99
Age-adjusted death rate for Population B= ×1000=22.7 per 1000 population
51,000

So, we observe that the age-adjusted death rate is higher in population A than in population B, which is
clearly in contrast to the conclusion based on crude death rate of the two populations (Table 4).

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Indirect Standardization: This method is used when the age-specific rates for the study population are
not available or are unknown. This method uses the observed number of deaths in the study population and
compares this to the number of deaths that would be expected if the age- specific death rates were the same as
that of the standard population. It is often used to study the mortality experience of an occupationally
exposed population.

Procedure for Indirect Standardization:

1. Choose a standard population.
2. Calculate the observed number of deaths in the population(s) of interest.
3. Apply the age-specific mortality rates from the chosen standard population to the population(s) of interest.
4. Multiply the number of people in each age group of the population(s) of interest by the age- specific
mortality rate in the comparable age group of the standard population to calculate number of expected
deaths.
5. Sum the total number of expected deaths for each population of interest.
6. Divide the total number of observed deaths of the population(s) of interest by the number of expected
deaths.
7. The ratio of the observed number of deaths to the expected number of deaths is called:
“Standardized Mortality Ratio” or SMR

Observed number of deaths

SMR= ×100
Expected number of deaths

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 Example: Calculation of expected deaths by applying indirect standardization method
Population A
Age group Population Age-specific mortality Expected
(years) rate (deaths per 1000)
0-24 2000 4.0 8.0
25-49 2500 7.0 17.5
50-74 3500 10.0 35.0
75 and above 4500 30.0 135.0
Total 195.5

Given the observed deaths in population A = 120

Dividing the total number of observed deaths by the total number of expected deaths,
120
SMR for Population A= ×100 =61.4%
195.5
Inference: An SMR of above 100 means the number of observed deaths is greater than what would be
expected if the study population had the same probability of dying as the standard population, while an
SMR of below 100 means the number of observed deaths is less than expected.

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Exercises
1. In 2010, there were 4,500 deaths due to lung diseases in miners aged 20 to 64 years. The expected
number of deaths in this occupational group based on age-specific death rates from lung diseases in all males
aged 20 to 64 years was 1800 during 2010. Calculate the standardized mortality ratio (SMR) for lung
diseases in miners.
2. The table below shows hypothetical data for a standard population for the number of admissions to
intensive care units (ICU) in a one-year period and the age- and sex- categories of these patients. Assess the
quality of care provided by the ICU of a hospital using standardized mortality ratio. There were 149
observed deaths in the hospital.
a) Calculate the SMR for a population using death rates of the standard population as provided in the
table.
b) Draw inference from the calculated SMR.
Age and sex Standard Age and sex
Standard Hospital Expected death
specific population specific death
population (population) in ICU
categories (Deaths) rate
20-39 male 1802 9523 37
40-59 male 4560 28199 77
60-79 male 8292 35303 128
>80 male 4620 11550 45
20-39 female 769 6202 25
40-59 female 6364 32569 79
60-79 female 6409 30628 122
>80 female 372 932 46
Total 33188 154906 559

3. Calculate age-adjusted death rates for the two communities shown in the table below. Compare adjusted
rates with the crude death rates of two communities. What difference do you observe? Finally give your
comments.
Community A Community B
Age group Deaths Population Rate per 1000 Deaths Population Rate per 1000
(years) population population

0-34 20 1000 20 180 6000 30

35-64 120 3000 40 150 3000 50
65 and over 360 6000 60 70 1000 70
Use the standard population as given in the table.
Age group (years) Standard population
0-34 3000
35-64 3000
65 and over 4000

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