Measurements of Morbidity and Mortality

6.1 Measurement of health

Epidemiology is mainly a quantitative science. Measures of disease frequency are the basic tools
of the epidemiological approach. Health status of a community is assessed by the collection,
compilation, analysis and interpretation of data on illness (morbidity), death (mortality),
disability and utilization of health services. The most basic measure of disease frequency is a
simple count of affected individuals. Such information is useful for public health planners and
administrators for proper allocation of health care resources in a particular community. However,
to investigate distributions and determinants of disease, it is also necessary to know the size of
the source population from which affected individuals were counted. One of the central concerns
of epidemiology is to find and enumerate appropriate denominators in order to describe and
compare groups in a meaningful and useful way. Such measures allow direct comparisons of
disease frequencies in two or more groups of individuals.

6.2 Ratios, proportions, and rates

Ratio

A ratio quantifies the magnitude of one occurrence or condition to another. It expresses the
relationship between two numbers in the form of x: y or x/y X k

Example: -

The ratio of males to females (M:F) in Ethiopia. -

The ratio of male malaria patients to female malaria patients.

Proportion

A proportion quantifies occurrences in relation to the populations in which these occurrences

take place. It is a specific type of ratio in which the numerator is included in the denominator and
the result is expressed as a percentage.

Example:

The proportion of all births that was male

Male births x 100

Male + Female births

Rate

Rate is the most important epidemiological tool used for measuring diseases. Rate is a special
form of proportion that includes time. It is 34 the measure that most clearly expresses probability
or risk of disease in a defined population over a specified period of time, hence, it is considered
to be a basic measure of disease occurrence. Accurate count of all events of interest that occur in
a defined population during a specified period is essential for the calculation of rate.

Rate = Number of events in a specific period xk

Population at risk of these events in a specified Period

Example:

The number of newly diagnosed pneumonia cases in 1999 per 1000 under five children.

6.3 Measurements of morbidity

Morbidity rates are rates used to quantify the occurrence of disease. Measures of morbidity
include incidence, period prevalence, and point prevalence rates.
Incidence rate

The incidence of a disease is defined as the number of new cases of a disease that occur during a
specified period of time in a population at risk for developing the disease. Incidence rate =
Number of new cases of a disease over a period of time XK

Total Population during the given period of time

The critical element in the definition of incidence is new cases of disease. Because incidence is a
measure of new events (i.e. transition from a non-diseased to a diseased state), incidence is a
measure of risk. The appropriate denominator for incidence rate is population at risk but
knowing the population at risk is difficult at this level. Hence, total population can be used as a
denominator. Another important issue in incidence is the issue of time. For incidence to be a
measure of risk we must specify a period of time and we must know that all of the individuals in
the group represented by the denominator have been followed up for that entire period. The
choice of time period is arbitrary: We could calculate incidence rate in one week, one month, one
year, 5 years, and so on. Incidence rates can be used to make statements about the risk of disease.
If the incidence rate of a certain disease is high in one area, then the risk of acquiring that disease
by other healthy individuals will be high.

Example. In Ginbot 1995 there were 50 new cases of relapsing fever in “Kebele X”. The average
total population of “Kebele X” was 5000. Calculate the incidence rate of relapsing fever in
“Kebele X” in Ginbot 1995.

Answer- Incidence rate = 50 X 1000 = 10 new cases per 1000 population

5000

That means out of every 1000 people living in “Kebele X”, 10 of them acquired relapsing fever
in Ginbot 1995. Another commonly used measure of morbidity is attack rate. Attack rate is a
type of incidence rate which is mainly used during epidemics.
Attack rate = No. of new cases of a specific disease reported during an epidemic Xk

Total population at risk during the same time

On Tir 7, 1995, 100 people were invited by Ato Alemitegnaw for dinner. All of them ate the
food that was served for dinner. The next day (Tir 8, 1995) 90 of the 100 people who ate that
food developed diarrhea. Calculate the attack rate of diarrhea which occurred on Tir 8, 1995.

Attack rate = 90 X 100 = 90 cases of diarrhea per 100 people

100

That means out of 100 people who ate the food served by Ato Alemitegnaw, 90 of them
developed diarrhea on Tir 8, 1995.

Uses incidence rate

Incidence rate is important as a fundamental tool for etiologic studies of diseases since it is a
direct measure of risk. If the incidence rate is significantly higher in one area, then the cause of
that disease can be systematically searched.

Prevalence rate

Prevalence rate measures the number of people in a population who have a disease at a given
time. It includes both new and old cases. The major type of prevalence is point prevalence rate.

Point Prevalence rate: measures the proportion of a population with a certain condition at a
given point in time. Point prevalence rate can be determined by conducting cross-sectional study.

Point Prevalence rate = All persons with a specific Condition at one point in time XK

Total population

Example: One health extension worker conducted a survey in one of the nearby elementary
schools on Hidar 10, 1996 to know the prevalence of trachoma in that school. The total number
of students in that school was 200. The health extension worker examined all the 200 students
for trachoma. Hundred students were found to have trachoma. 38 Calculate the point prevalence
rate of trachoma for that school.

Point prevalence rate= 100 X 100 = 50 trachoma patients per 100 students on

200 Hidar10,1996

That means 50 % of the students in that elementary school were affected by trachoma on Hidar
10, 1996.
Uses of prevalence rate

i. Planning health facilities and human resource

Ii. Monitoring chronic disease control programs like tuberculosis control program

6.4 Measurements of Mortality

Mortality rates and ratios measure the occurrence of deaths in a population using different ways.
Rates whose denominators are the total population are commonly calculated using either the mid
- interval population or the average population. This is done because population size fluctuates
over time due to births, deaths and migration.

Population count at the beginning + Population count

Average population = at the end of the time interval considered

2

Below are given some formulas for the commonly used mortality rates and ratios.

1. Crude Death rate (CDR)

CDR = Total no. of deaths reported during a given time interval X 1000

Estimated mid interval population

The Crude Death Rate measures the proportion of the population dying every year, or the
number of deaths in the community, per 1000 population. It reflects the risk of death in that
community or country. Currently the Crude Death Rate in Ethiopia is 12.6 per 1000 population
(1995 health & health related indicators, MOH). That means out of 1000 total population about
13 people die each year.

2. Age- specific mortality rate

= No. of deaths in a specific age group during a given time X 1000

Estimated mid interval population of specific age group

One example of age specific mortality rate is Infant Mortality Rate.

3. Sex- specific mortality rate

= No. of deaths in a specific sex during a given time X 1000

Estimated mid interval population of same sex

Example: The average total population of “Kebele Y” in 1996 was 6000 (3500 female & 2500
male). In the same year 300 people died (100 female & 200 male). Calculate the mortality rate
(Crude death rate) for females.
CDR for females = 100 X 1000 = 29 per 1000 female population

3500

That means out of 1000 female population living in “Kebele Y”, 29 females died in 1996.

4. Proportionate mortality ratio

= No. of deaths from a specific cause during a given time x 100

Total no. of deaths from all causes in the same time

The proportionate mortality ratio asks the question: What proportion of deaths are due to a
certain cause? For example when we say the proportionate mortality ratio for HIV/AIDS is 30 %,
this means out of 100 total (of all) deaths 30 of them died from HIV/AIDS.
4. Case Fatality Rate (CFR)

= No. of deaths from a specific disease during a given time x 100

No. of cases of that disease during the same time

Case fatality rate represents the probability of death among diagnosed cases or the killing power
of a disease.

Example: In 1996 there were 1000 tuberculosis patients in one region. Out of the 1000 patients
100 died in the same year. Calculate the case fatality rate of tuberculosis.

CFR = 100 x 100 = 10 %

1000

That means 10% of tuberculosis patients will die once they develop the disease

5. Neonatal Mortality Rate

= No. of deaths under 28 days of age reported during a given time X 1000

No. of live births reported during the same time

Example: In 1996 there were a total of 5000 live births in “Zone B”. Two hundred of them died
before 28 days after birth. Calculate the Neonatal Mortality Rate (NMR).

NMR = 200 X 1000 = 40 per 1000 live births

5000

That means out of 1000 live births in 1996, 40 of them died before 28 days after birth. Death
during the neonatal period is largely due to prematurity, malformations, accidents or injuries at
birth, and lack of cleanliness and sterility during or after delivery. In addition, it reflects the
inadequacy of antenatal care.
6. Infant Mortality Rate (IMR)

= No. of deaths under 1 year of age during a given time X 1000

No. of live births reported during the same time interval

Infant mortality rate reflects the health of the community in which the child is being brought up.
Thus, it is high among people who have little health care, chiefly because infections, such as
pneumonia, diarrhea and malaria, are common among their infants. Malnutrition is also one of
the killer of infants in developing countries. The infant mortality rate in Ethiopia is one of the
highest in the world (96.8 per 1000 live births). That means out of 1000 live births about 97 die
before they celebrate their first birth day.

7. Under- five mortality rate

= No. of deaths of 0-4 years of age during a given time X 1000

Average (mid-year) population of the same age at the same time

NB: The numerator says 0-4 years. 0-4 years in this formula means children from birth to less
than five years of age i.e the upper age limit is not 4.

Example: In 1996 the total number of children under 5 years of age was 10,000 in “Zone C”. In
the same year 200 children under five years of age died. Calculate the under five-mortality rate
(U5MR).

U5MR = 200 x 1000 = 20 per 1000 under five children

10,000

That means in “Zone C”, out of 1000 under five children, 20 died in 1996.

8. Maternal Mortality Rate

= No. of pregnancy associated deaths of mothers in a given time X 100,000

No. of live births in the same time

Maternal Mortality Rate reflects the standards of all aspects of maternal care (antenatal, delivery
and postnatal). The Maternal Mortality Rate in Ethiopia is estimated to be 871 per 100,000 live
births. That means in 100,000 live births, around 871 mothers die each year due to pregnancy
related causes.

Exercise: The following information is about kebele X which was collected for the year 1999:

– Total average population = 40,000

– Total number of live births = 4000

– Total number of deaths = 400

– Total number of deaths before the age of 28 days = 50

– Total number of infant deaths = 200

– Number of women who died from pregnancy related causes = 160

– New cases of tuberculosis = 100

– All cases of tuberculosis = 300

– Deaths from tuberculosis = 60

Based on the above information calculate the following. 1. The incidence rate of tuberculosis. 2.
The period prevalence rate of tuberculosis. 3. The case fatality rate of tuberculosis. 4. The
Neonatal mortality rate. 5. The infant mortality rate. 6. The maternal mortality ratio