Morbidity and Mortality

Dr. Akera Peter

Faculty of Medicine
Gulu University
10/05/2023
 Measuring health and Disease

• Why ?

• How?
 Key messages
• The measure of health and disease is
fundamental to the practice of epidemiology.
• A variety of measures are used to characterize
the overall health of populations.
• Population health status is not fully measured
in many parts of the world, and this lack of
information poses a major challenge for
epidemiologists.
 Definitions
• What is morbidity?

• What is mortality?
 Definitions
• Practical definitions of health and disease are
needed in epidemiology -easily measurable
and amenable to improvement.
• Definitions of health states used by
epidemiologists tend to be simple - disease
present” or “disease absent” .
 Definitions
• The development of criteria to establish the
presence of a disease requires a definition of
“normality” and“ abnormality.”

• However, it may be difficult to define what is

normal, and there is often no clear distinction
between normal and abnormal
 Definitions
• Especially regarding normally distributed
continuous variables that may be associated
with several diseases e.g. BP, BS for Malaria,
Diabetes

• A specific cut-off point for an abnormal value

is based on an operational definition and not
on any absolute threshold.
Diagnostic criteria /Case definition
• What disease is someone suffering from?
• Diagnostic criteria - based on symptoms, signs,
history and test results.
• Examples
• Hepatitis - identified by the presence of
antibodies in the blood;
 Examples
• asbestosis - symptoms and signs of specific
changes in lung function, radiographic
demonstration of fibrosis of the lung tissue or
pleural thickening, and a history of exposure
to asbestos fibers.
• Rheumatic fever -diagnosis can be made
based on several manifestations of the
disease, with some signs being more
important than others.
 Examples
• In some situations, very simple criteria are
justified e.g., bacterial pneumonia in children
in developing countries - case detection
based on clinical signs alone, no auscultation,
chest radiographs nor laboratory tests.

• What of Malaria in Uganda?

• HIV
Diagnostic criteria/case definitions
• Diagnostic criteria may change quite rapidly as
knowledge increases or diagnostic techniques
improve
• Definition for HIV/AIDS in 1985 vs now!
• The above definitions of disease are case
definitions
 Measuring disease frequency
• Population at Risk - key
• correct estimate of the numbers of people under
study
• Ideally should only include people who are
potentially susceptible to the diseases being studied
• What is the population at risk for studying cervical
cancer?
• Pediatric ART,
• malaria in under 5s etc
 Population at risk
• The people who are susceptible to a given
disease are called the population at risk
• Can be defined by
- Demographic
- geographic
- environmental factors.
 Incidence and Prevalence
• Both measures of morbidity
• Incidence : the rate of occurrence of new
cases arising in a given period in a specified
population
• Prevalence: is the frequency of existing
cases in a defined population at a given point
in time
 Incidence and Prevalence
• Different ways of measuring occurrence
• The relation between incidence and
prevalence varies among diseases
- There may be low incidence and a high
prevalence – as for diabetes
- Or a high incidence and a low prevalence – as
for the common cold.
 Incidence vs Prevalence
Incidence Prevalence
1. Numerator. Number of 1. Number of existing cases of
new cases of disease disease at a given point of
during a specified period of time
time
2. Denominator. Population 2. Population at risk
at risk
3. Focus . Whether the event 3. Presence or absence of
is new disease
4. Time of onset of disease 4. Time period is arbitrary. A
“snapshot” in time
 Incidence vs Prevalence
Incidence Prevalence
• Uses • Uses
1. Express the risk of 1. Estimates the probability
becoming ill of the population being ill
2. Main measure of acute 2. Useful in the study of
diseases or conditions, but burden of chronic disease
also used for chronic and implication for health
diseases services
3. Useful to study causation
 Incidence and prevalence
• Measuring involves the counting of cases in
defined populations at risk.
• Note: Reporting the number of cases without
reference to the population at risk can be used
- give an impression of the overall magnitude of
a health problem,
- short-term trends in a population, for instance,
during an epidemic.
 “Attack Rates”
• “Attack rate” is often used instead of
incidence during a disease outbreak in a
narrowly-defined population over a short
period of time.
• The attack rate can be calculated as the
number of people affected divided by the
number exposed.
 Attack rate
• E.g. food borne disease outbreak (food
poisoning )
• The attack rate can be calculated for each type
of food eaten, and then these rates compared
to identify the source of the infection.
 Incidence
• Incidence refers to the rate at which new
events occur in a population

• Incidence takes into account the variable time

periods during which individuals are disease-
free and thus “at risk” of developing the
disease.
 Incidence
• In the calculation of incidence, the
numerator is the number of new
events that occur in a defined time
period, and the denominator is the
population at risk of experiencing the
event during this period
 Incidence
• Incidence malaria will be given by

# of persons developing malaria with in a

given period of time X 10n
Population at risk
• The units of incidence rate must always
include a unit of time (cases per 10n and per
day, week, month, year, etc.).
 “Person-time incidence rate”
• Each person in the study population
contributes one person-year to the
denominator for each year (or day,
week, month) of observation before
disease develops, or the person is
lost to follow-up.
 Person-time incidence rate”
• For each individual in the population, the time
of observation is the period that the person
remains disease-free.
• The denominator used for the calculation of
incidence is therefore the sum of all the
disease-free person-time periods during the
period of observation of the population at
risk.
 Cumulative incidence
• Simpler measure of the occurrence of a disease
or health status.
• Unlike incidence, it measures the denominator
only at the beginning of a study
• Presented as cases per 1000 population.
• Is the probability that individuals in
the population get the disease during the
specified period
• Measured in years often a lifetime
 Prevalence
Calculated as follows

# of people with disease or condition at

specified time x 10 n
# of people on a population at risk at the
specified time
 Point prevalence
• Prevalence is often expressed as cases per 100
(percentage), or per 1000 population

• If the data have been collected for one point

in time, P is the “point prevalence rate.”
 Period prevalence
• More convenient to use
• Calculated as the
• total # of cases at any time during a specified
period, divided by the population at risk
midway through the period.
• Similarly, a “lifetime prevalence” is the total
number persons known to have had the
disease for at least some part of their lives.
 Case fatality
• Case fatality is a measure of disease
severity and is defined as the
proportion of cases with a specified
disease or condition who die within a
specified time.
• It is usually expressed as a
percentage.
 Case fatality

# of deaths from diagnosed cases in a given

period x 10 n
# of diagnosed cases of the disease in the
same period
 Death rate or crude mortality rate
• The death rate or crude mortality rate (CMR)
for all deaths or a specific cause of death is
calculated as follows:
• CMR =
# of deaths during a specified period × 10n
# of persons at risk of dying during
the same period
 CMR
• Disadvantage - that it does not take into
account the fact that the chance of dying varies
according to age, sex, race, socioeconomic class
and other factors.
• It is not usually appropriate to use it for
comparing different time periods or
geographical areas.
• Thus use age standardized rates (for different
age groups)
 Age-specific death rates

• Death rates can be expressed for specific

groups in a population defined by age, race,
sex, occupation or geographical location, or
for specific causes of death.

• For example, an age- and sex-specific death

rate is defined as:
 Age-specific death rates

Total # of deaths occurring in a specific age

and sex group of the population in a defined
area during a specified period x 10 n
Estimated total population of the same age
and sex group of the population in the same
area during the same period
 Infant mortality

• Measure of overall health status for a given

population is based on the assumption that it
is particularly sensitive to socioeconomic
changes and to health care interventions
• It measures the rate of death in children
during the first year of life, the denominator
being the number of live births in the same
year.
 IMR
• The infant mortality rate is calculated as
follows:
• IMR =

# of deaths in a year of children less than 1

year of age X 1000
# of live births in the same year
 Child mortality rate

• The child mortality rate (under-5 mortality

rate) is based on deaths of children aged 1–4
years
• Used as a basic health indicator
• Injuries, malnutrition and infectious diseases
are common causes of death in this age group.
• Describes the probability (expressed per 1000
live births) of a child dying before reaching 5
years of age.
 Maternal Mortality Rate
• MMR refers to the risk of mothers
dying from causes associated with
delivering babies, complications of
pregnancy or childbirth

• Difficult to calculate accurately

 MMR

MMR=
Number of maternal deaths in a given
geographic area in a given year______x 10 n
Number of live births that occurred among
the population of the given geographic area
during the same year
 MMR
• Ranges from about 3 per 100 000 live births in
high-income countries to over 1500 per 100
000 live births in low-income countries

• UG?
• MDG
 Adult mortality rate
• Is the probability of dying between the ages of
15 and 60 years per 1000 population.
• The adult mortality rate offers a way to
analyze health gaps between countries in the
main working age Groups
• The probability of dying in adulthood is
greater for men than for women in almost all
countries
 Adult mortality rate
• The variation between countries is very large.
In Japan, less than 1 in 10 men (and 1 in 20
women) die in these productive age groups,
compared with almost 2 in 3 men (and 1 in 2
women) in Angola
 Life expectancy
• Life expectancy is another summary measure
of the health status of a population

• It is the average number of years an individual

of a given age is expected to live if current
mortality rates continue
 Life expectancy
• It is not always easy to interpret the reasons
for the differences in life expectancy between
countries;
• different patterns may emerge according to
the measures that are used.
 Age-standardized rates

• An age-standardized death rate (also referred

to as an age-adjusted rate) is a summary
measure of the death rate that a population
would have if it had a standard age structure

• Standardization can also be done for variables

other than age
 Age-standardized rates
• Age-standardized rates enable comparisons to
be made between populations that have
different age structures.
• The age-standardization of rates eliminates
the influence of different age distributions on
the morbidity or mortality rates being
compared.
 Sources of Data (mortality)
• Vital registration systems (Death and birth registries)
• Verbal autopsy
• House hold surveys - Uganda Demographic and
Health Survey (UDHS) , DSS- Gulu, Awach
• Special longitudinal investigations (e.g., maternal
mortality studies)
• Health facility registries

• Death certificates?????
 Sources of Data (morbidity)

• The major methods for gathering morbidity

data are through surveillance systems and
sample surveys.
• Both procedures are very costly
• Used only selectively in developing country
setting to gather data on health problems of
major importance eg.HIV sero-survey –
Uganda