1. The proportion of infants who are born alive with a defect of the ventricular septum of the heart is a prevalence or incidence? Slide 53

2. Prevalence proportion is used more in public health than in causal research However, there are research areas in which prevalence measures are used more commonly than incidence measures, e.g., birth defects (when we describe occurrence of congenital malformations among live- born infants in terms of proportion of these infants who have a malformation), diseases that are difficult to define onset (diabetes, hypertension)

3. PREVALENCE MEASURES Slide 44 – Slide 53

4. DISEASE FREQUENCY Both incidence proportion and incidence rate are measures that assess frequency of disease onset Prevalence proportion is a measure of disease status

5. PREVALENCE MEASURES Prevalence is the frequency of existing cases

6. Measles in a cohort of unimmunized infants Healthy Baby Measle Infected Baby Immuned Baby Modified from Ralph Frerichs, UCLA (http://www.ph.ucla.edu/epi/200/epi200_01.html)

7. 1 2 3 4 5 6 7 Weeks Five babies observed for 7 wks for measles

8. For point prevalence, watch the blue bar 1 2 3 4 5 6 7 Weeks

9. Prevalence is calculated by: Number of people with the disease or condition at a specific time P = Total population at a specific time

10. How many babies had measles at week 2? 1 2 3 4 5 6 7 Weeks 1

11. How many total population at week 2? 1 2 3 4 5 6 7 Weeks 5

12. 1 existing case in a population of 5 babies 1 Prevalence == 0.2 = 20% 5 Point prevalence is: The proportion of the population affected by a disease at a specific point in time

13. PERIOD PREVALENCE Period prevalence is calculated by: Number of incident and prevalent cases identified during a given period P = Size of the total population during the period

14. For period prevalence, watch the green bar 1 2 3 4 5 6 7 Weeks

15. How many babies had measles during weeks 2-4? 1 2 3 4 5 6 7 Weeks 3

16. How many baby population during week 2-4? 1 2 3 4 5 6 7 Weeks 5

17. 3 existing case in a population of 5 babies 3 Period revalence == 0.6 = 60% 5 Period prevalence is: The proportion of the population affected by a disease anytime during a given period

18. INTERPRETATION OF PREVALENCE Because prevalence reflects both incidence rate and disease duration, it is not as useful as incidence for studying causes of disease. It is useful for measuring disease burden on a population, especially if those who have the disease require specific medical attention.

19. RELATIONSHIP BETWEEN PREVALENCE AND INCIDENCE Prevalence is less useful than incidence in etiologic studies, because it is a function of incidence rate ( ) and duration of disease ( ) Assumption: prevalence, incidence rate and mortality rate remain constant over time, no in- and out-migration I

20. RELATIONSHIP BETWEEN PREVALENCE AND INCIDENCE If the disease is rare, = mean duration of disease Assumption: prevalence, incidence rate and mortality rate remain constant over time, no in- and out-migration

21. Four million people are dying from tobacco per year! Slide 56 – Slide 65

22. Prevalence - example You are the new hospital epidemiologist in a busy tertiary care hospital in Hanoi On your first day at work the hospital director asks you to review the hospital data and tell the staff about Ventilator Associated Pneumonia (VAP)

23. Prevalence - example You notice that there are 3 cases of VAP in the hospital today of 498 hospitalized patients

24. Prevalence - example You notice that there are 3 cases of VAP in the hospital today of 498 hospitalized patients At the morning staff meeting you announce that the point prevalence of VAP is 0.6% The director pulls you aside later and asks you to do some more work

25. Incidence - example You find 24 cases of VAP over the last year at your hospital and a medical records staff person tells you that 148,637 total patients were given care in the last year and 32,648 patients were hospitalized

26. Incidence - example You find 24 cases of VAP over the last year at your hospital and a medical records staff person tells you that 148,637 total patients were given care in the last year and 32,648 patients were hospitalized At the morning staff meeting you announce that the incidence rate of VAP is.02% per year

27. Incidence - example You find 24 cases of VAP over the last year at your hospital and a medical records staff person tells you that 148,637 total patients were given care in the last year and 32,648 patients were hospitalized At the morning staff meeting you announce that the incidence rate of VAP is.02%/year The director pulls you aside later and asks you to do some more work

28. Incidence - example You decide to become friends with the staff in medical records Working with a staff person you determine that 272 persons were on a ventilator during the last year

29. Incidence - example You decide to become friends with the staff in medical records Working with a staff person you determine that 272 persons were on a ventilator during the last year At the morning meeting you announce that the incidence proportion (risk) of VAP is 8.8% The staff are confused and ask why the numbers keep changing

30. Incidence - example The staff asks if this is the most useful information you can provide regarding risk of VAP

31. Incidence - example The staff asks if this is the most useful information you can provide regarding risk of VAP You say yes

32. Incidence - example The staff asks if this is the most useful information you can provide regarding risk of VAP You say yes The director says no and asks you to do some more work

33. Incidence - example You stay up very late with your friend from medical records Together, you determine that the 272 patients had a grand total of 1,105 days on the ventilator

34. Incidence - example You stay up very late with your friend from medical records Together, you determine that the 272 patients had a grand total of 1,105 days on the ventilator At the morning staff meeting, you announce that the incidence rate of VAP is 2.17 per 100 ventilator days The staff cheers

35. Incidence - example The director asks the staff to stop cheering and asks you to do some more work The director also says that you may show some promise

36. Incidence - example You stay up all night with your friend from medical records Together, you determine that of the 1,105 days on the ventilator you previously counted, 221 occurred after VAP

37. Incidence - example You stay up all night with your friend from medical records Together, you determine that of the 1,105 days on the ventilator you previously counted, 221 occurred after VAP At the morning staff meeting, you announce that the correct incidence rate of VAP is 2.71 per 100 ventilator days The staff cheers again, and asks that you attend a different meeting tomorrow morning

38. Incidence - example The director asks the staff to stop cheering and asks you to stratify by hospital day and calculate incidence of VAP by strata of days on ventilator You ask the director if he will support your attendance in a month long intro to field epi course in Bangkok The staff cheers, except for your friend in medical records

39. Incidence - example The director agrees and says he has a great new project in mind regarding the occurrence of diarrhea in patients while on antibiotic therapy He asks you to present initial results at the first meeting after you get back to the hospital The staff does not cheer

40. CASE FATALITY Case fatality risk (CFR) is defined as: The probability of a case dying from the disease during a given period CFR is calculated by: Number of deaths from a disease during a specified period after disease occurrence CFR = Number of incident cases of the disease during that period

41. 11. Compute case fatality risk: should fine better data

42. BASIC CONCEPTS OF MEASUREMENT Ratio: a ratio expresses the relationship between two numbers in the form x : y Proportion: a proportion is a fraction in which all elements of the numerator are included in the denominator Rate: a rate is an instantaneous change in one quantity per unit of time

43. INFANT MORTALITY RATIO Number of deaths in a year of children less than 1 year of age = Number of live births in the same year Perinatal mortality: 28 wks gestation 1 wk of life Neonatal mortality: 1st month of life Post neonatal mortality: 1 month 1 year

44. KAPLAN-MEIER CURVE 0 2 4 6 8 10 12 14 16 18 20 22 24 Cumulative survival Time (months) Modified from fig. 2-1 in M. Szklo, F. Nieto. Epidemiology Beyond the Basics. Maryland: Aspen Publishers; 2000 1 year survival = ? 90% 79% 67% 54% 36% 18% 2 year survival = ? median survial = ?