BIOSTATISTICS AND EPIDEMIOLOGY

- De jure – enumeration of individuals as of where

they usually reside, regardless of where they are
- Tools used to measure objectively a specific on census day.
health concept of interest - De facto is used in the Philippines
- Usually numerical measures which help compare YEAR POPULATION SIZE ANNUAL GROWTH RATE (%)
the targeted or expected results of health 1948 19,234,182 2.07
programs 1960 27,087,685 2.89
- Examples are health status, accessibility, 1970 36,684,486 3.08
coverage, and utilization of health services 1975 42,070,660 2.78
- An indicator may provide a direct estimate of the 1980 48,098,460 2.71
underlying condition of interest 1990 60,703,206 2.35
o Ex. Weight for height → wasting 1995 68,616,536 2.32
- It can also serve as a proxy for a condition or 2000 76,506,928 2.34
phenomenon which is difficult to measure 2007 88,566,732 2.04
o Ex. Socio-economic status of a family → 2010 92,337,852 1.90
occupation or monthly income of the 2015 100,979,303 1.72
head of the household
Vital Registration System
USES OF HEALTH INDICATORS - VRS, requires basic and compulsory registration
• To define public health problems at a particular of all births, deaths, and marriages occurring in
point of time the country
• To indicate changes over time in the level of - Obligatory
health of an individual or a population - It was legally instituted in the country on
• To assess the extent to which the objectives of a February 27, 1931
program are being reached - PSA is in-charge of the VRS
• To inform, educate, and empower people about - Main Problem: under-registration of births and
health issues deaths

CHARACTERISTICS OF INDICATORS National Health Information System

➢ Valid – the indicator measures what is supposed ➢ Philippine Integrated Disease Surveillance and
to be measured Response (PIDSR) – enhanced surveillance
➢ Reliable – the indicator will have the same value system that monitors notifiable diseases and
even of it is measured by other people at other health-related events of public health
different times under similar conditions. It importance
should also have consistency! o Category 1: 10 diseases: measles,
➢ Sensitive – able to detect small changes in the human avian influenza, anthrax,
phenomenon being measured in a significant neonatal tetanus, rabies, and SARS
way among others
➢ Specific – the indicator reflects changes only in ▪ Immediate notification within
the situation concerned 24 hours
➢ Feasible – collection of data to determine its o Category 2: 17 diseases: acute bloody
value if technically, financially, and operationally diarrhea, cholera, dengue, leptospirosis,
possible malaria, typhoid and paratyphoid fever,
RELIABILITY FEASIBILITY and pertussis among others
Pallor of conjunctiva ✗ ✓ ▪ Weekly notification
Anemia
Hbg level ✓ ✗ ➢ Field Health Service Information System (FHSIS)
DNA ✓ ✗ o Intended to address the short-term
Paternity
Ask the mother ✗ ✓ needs of DOH and LGU staff with
managerial or supervisory functions in
facilities and program areas.
SOURCES OF DATA FOR HEALTH INDICATORS
o Provides summary on health service
Census of the country’s population delivery and selected program
- Complete count of the population of a given accomplishment indicators
place ➢ Hospital Operation and Management
- First recorded value of the population of Information System (HOMIS)
Philippines was documented by Fr. Buzeta in o Computer based system developed by
1799 with a count of 1,502,574 DOH with the objective of supporting
- First known Philippine census was conducted in the hospital management for effective
1877 with a count of 5,984,727 and quality health care
- The most recent census was conducted in 2015 o To systematically collect, process, store,
with a count of 100,979,303 present, and share information in
- De facto – enumeration of individuals as of support of hospital functions
where they are found in the census, regardless
of where they normally reside.
 BIOSTATISTICS AND EPIDEMIOLOGY

Specialized Information Systems within the Health ➢ Specific rates

Sector o describes only a specific sub-group of
➢ Event/condition-specific information and the total population being considered
surveillance systems o denominator: belonging to a specific
o Surveillance in post-extreme subgroup (ex. age, sex, occupation, etc.)
emergencies and disasters (SPEED) o Example: Age-specific death rate (ASDR)
Total no.of deaths in a specified age group
o Online National Electronic Injury in a defined area during a specified period
𝑥 1000
Mid year population of the specified age group
Surveillance System (ONEISS)
o Philippine Malaria Information System
(PhilMIS) According to time covered by the events
➢ Disease Registries ➢ Point in time
o Cancer Registry o occurred during the specific point in
o HIV/AIDS Registry time being considered
o incidence (new cases) of diseases during
Sample Surveys outbreak or epidemic
Number of new case occuring in a place
➢ National Demographic and Health Survey in a given period of time
𝑥 100
Number of population at risk in a place
(NDHS) in a given period of time
o Collecting accurate and nationally o Example: incidence of diarrhea on June
representative data on health, 30, 2022
population, and nutrition in developing ➢ Period of time
countries o occurred over a period of time
o Funded by USAID o prevalence (old and new cases)
o Started in 1984 and has covered 90 Number of existing cases in a place at a given time
Total population in a place at a given time
𝑥 100
countries including Philippines o Example: prevalence of diabetes from
o Important in policy making, program January to December 2022
planning, monitoring, and evaluation of
programs According to components of the evaluation
➢ Multiple Indicator Cluster Surveys (MICS) framework
o Series of household surveys conducted
by UNICEF covering important indicators ➢ Input indicators – resources needed to deliver
describing the situation of women and the essential services to the population or to
achieve project objectives
children
o First was conducted in 1995 o Number of posters and brochures on
family planning
o Last MICS in the Philippines was in 2014
o Number of community volunteers
➢ Young Adult Fertility and Sexuality Study (YAFS)
trained to conduct health education
o Series of national surveys on Filipino
➢ Output indicators – direct products of project
youth aged 15-24
activities. Generally in the form of activities and
o One of primary sources on sexual and
processes undertaken (size and scope)
non-sexual risk behavior and its
determinants in the Philippines o Number of couples who have seen or
received the posters
o Number of health education classes
TYPES OF HEALTH INDICATORS conducted
According to aspect of health being measured ➢ Outcome indicators – immediate result of the
➢ Health status indicators services or activities implemented; changes of
o measure health outcomes (effects, behavior in the community
illnesses, disabilities, injury, and death) o % Increase in the level of knowledge
and/or their risk factors (personal, among couples on family planning
environmental, or occupational) o % Increase in number of family planning
➢ Health service performance indicators acceptors
o measure aspects of the performance of ➢ Impact indicators – intended or unintended long
health services or public health term organizational/community changes
programs (sustainability or innovation/changes)
o utilization, accessibility, quality, and o decrease in the average number of
costs of health service children per family
o decrease in the population growth rate
According to group referred to
➢ Crude rates CONVENTIONAL HEALTH STATUS INDICATORS
o describes the total population which is Measures of Fertility (Births)
used as the denominator in the ➢ Crude Birth Rate (CBR)
computation o # of children born per 1000 population in
o denominator: total population being a given place and time
measured o Formula:
o Example: Crude death rate (CDR) Total number of livebirths in a year
Total No. of Deaths from all causes in 1 year 𝑥 1000
Midyear population in the same year
𝑥 1000
No. of persons in the population at mid year
 BIOSTATISTICS AND EPIDEMIOLOGY

➢ General Fertility Rate (GFR) o Formulas:

# of new cases that developed during the period
o # of children born per 1000 women in 𝑥F
# of person−time at risk
the reproductive age groups in a given or
place during a particular time # of new cases that developed during the period
𝑥F
o Formula: ave. popln′ x duration of follow−up
Total number of livebirths in a year
𝑥 1000
midyear female population aged 15 to 49 HOSPITAL A HOSPITAL B
in the same year Patient # # of days in hospital Patient # # of days in hospital
➢ Age-Specific Fertility Rate (ASFR) 1 3* 1 15*
2 5 2 25
o # of children born per 1000 women in a 3 1 3 8*
particular age group 4 10* 4 12
o measures fertility level of each sub- 5 6* 5 30*
* Developed nosocomial infection
group of women according to age
o Formula: ✓ Compute for IP/CI
Total number of livebirths registered to o Hospital A: 3/5 x 100 = 60%
women of a given age group during a year
Midyear female population on the same 𝑥 1000 o Hospital B: 3/5 x 100 = 60%
age group during the same year ✓ Compute for IR/ID
➢ Total Fertility Rate (TFR) o Hospital A: 3/25 x 100 = 12 per 100
o # of children who will be born per person days
woman if she pass through the o Hospital B: 3/90 x 100 = 3.33 per 100
childbearing years bearing children person days
o Formula:
TFR = ΣASFR (for single-year age group) Types of Prevalence Measures
TFR = 5 (ΣASFR) (for 5yr age grp) ➢ Point Prevalence
o measures the proportion of existing
Measures of Morbidity (Diseases) cases of a disease in the population at a
Measures of Association particular point in time.
- Quantifies the strength of the relationship o Useful in describing the magnitude of
between the disease/condition of interest and chronic conditions existing in a
the corresponding exposure/risk factors being population at a point in time.
assessed o does not measure the risk of developing
the disease
Measures of Disease Frequency o Formula:
no. of existing cases of a disease at a point in time
𝑥 100
- Magnitude of the disease in a given population population at that point in time

ATTRIBUTE INCIDENCE PREVALENCE ➢ Period Prevalence

Question being How many people How many o equal to the prevalence at the beginning
answered developed the people have the of the period plus the new cases and
disease? disease? recurrences during the said period
Events in the Number of new Number if
o useful for quantifying diseases
numerator cases of a disease existing cases of
a disease frequency
Type of diseases Acute Chronic o Difficulty in defining the onset of disease
usually referred to o Difficulty on determining whether the
Usual area of Disease Service delivery disease is present or absent in a given
application etiology/causation day
o Formula:
Types of Incidence Measures no. of existing cases of a disease during a period of time
population at the same period of time
𝑥 100
➢ Incidence Proportion (IP) or Cumulative
Incidence (CI) Other Morbidity Measures
o The proportion of disease-free - Ave. # of episodes of a disease
individuals who contract the disease - Severity of the disease
within a specified period of time - Burden of Disease: takes into account not only
o Called “attack rate” for infection when the # of persons sick of a given disease but also
the implicit reference period is the the effects of the disability and premature
duration of the outbreak mortality from the disease
o range of values: 0-1 (0-100%) o Indicator is DALY (Disability-Adjusted
o Formula: Life Years): Time-based measures that
No.of new cases that developed during the period
𝑥 100
No. of at risk of developing the disease during the period combines YLL and YLD
➢ Incidence Rate (IR) or Incidence Density (ID) ▪ Number of years life lost (YLL)
o measures the rate at which new cases due to premature mortality
occur ▪ Number of years lived with
o Deals with dynamic population – uses disability (YLD)
total person time as its denominator
o Person Time: a function of the size of the Measures of Mortality (Deaths)
population followed-up and the
A Risk of dying is measured by the crude and specific
duration of the follow-up time
death rates
▪ Sum of the individual
➢ Crude death rate
observation periods for each
o measures how fast mortality occurs in a
subject in the population
given population
 BIOSTATISTICS AND EPIDEMIOLOGY

o affected by age-sex composition, ➢ Life Expectancy at Birth

adverse environmental and o Average number of years that the
occupational conditions, peace, and newborn is expected to live if the current
order conditions mortality rates continue to apply
o Formula: o reflects the overall mortality level of a
Total deaths in one year population
𝑥 1000
midyear population
o the life expectancy in the Philippines for
➢ Specific mortality rate
the year 2011 is 70 years old – WHO
o measures the force of mortality in
specific subgroups of the population
no. of deaths in a specified group in a calendar year
𝑥F
COMPUTING INDICATORS
midyear population of the same specified group
o Example: Absolute numbers
no. of deaths among those 15−60 yrs old in 2021
𝑥F - simple count of the number of persons, houses
2021 midyear population aged 15−60 yrs old
➢ Cause-of-death rate or events being considered
o mortality rate from specific diseases or - easy to understand but difficult to interpret
conditions especially when making comparisons among
o used in determining the leading cause of groups with different sizes
mortality - Example:
o Formula:
no. of deaths from a certain cause in a calendar year
𝑥F
midyear population
➢ Infant mortality rate
o useful indicator of a country’s level of
health development
o component of Physical Quality Life Index
o can be artificially lowered by improving
birth registration
o Formula: Ratios
deaths under 1 year of age in a calendar year
𝑥 1000
number of LB in the same year - result of dividing one number by another
oMay be divided into: - reserved for measures wherein the numerator is
▪ Neonatal mortality rate: not part of the denominator
include deaths in the first 28 a
days of life -
b
▪ Post-neonatal mortality rate: - Example: sex ratio (male/female)
include deaths in the after 28
days of life but before 1 year Proportions
➢ Maternal mortality rate - special kind of ratio wherein the numerator is
o measures occurrence of maternal part of the denominator
deaths a
o “death while pregnant or within 42 days -
a+b
of termination of pregnancy” – WHO - When multiplied by 100, it is called as
𝑎
o reflects level of obstetric risk in a percentage (𝑎+𝑏 𝑥 100 = %)
population - Examples:
o ideal denominator: no. of pregnancies o % of infants who are fully immunized
o Formula: o % of households with sanitary toilets
all maternal deaths occuring in a calendar year
𝑥 1000
number of LB in the same year
➢ Proportionate mortality rate Rates
o measures the proportion occurring in a
- measures how fast an event occurs over time or
particular population group or from a
space
particular case
- expressed in terms of the frequency of
o difference with specific mortality rate
occurrence of events
▪ denominator used is the total
- common example in health is the incidence rate
number of deaths and NOT
of a disease.
midyear population
- Video-like
o Formula:
no. of deaths from a specific group or cause
𝑥F
total deaths in a year FORMULA FOR RATE, RATIO, AND PROPORTION
➢ Case-fatality rate 𝑎
o High CFR means disease is fatal = 𝑥 𝑘
𝑏
o Formula: - a: # of persons or events being considered
no. of deaths from a specific cause
𝑥F - b: size of the group to which the number in the
no. of cases of the same disease
➢ Under-five Mortality Ratio numerator is being related to
o Risk of a child born in a specific year or - k: factor (100, 1000, 10000, 100000 or even 1M)
period dying before reaching the age of o To make the resulting number easier to
five interpret
o Formula: o The rarer the condition, the bigger the
no. of children who died by the age of five
𝑥 1000
factor
no. of LB in the same year
 BIOSTATISTICS AND EPIDEMIOLOGY

o Interpreted as the number of males for

every 100 females in the population
- The scientific study of human populations Male
o Population size o Female
𝑥 100
o Population structure/composition
o Population distribution in space Population Pyramid
- “Study of the size, territorial distribution, and - Graphical presentation of the age and sex
composition of the population, changes therein, - Special type of histogram: male is shown at the
and the components of such changes” – Hauser left and female at the right
and Duncan (1959:2) - Youngest age group is the base and the oldest is
the top
POPULATION SIZE - Either the actual population count, or the
- Affected by: percentage of the population can be graphed.
o Natality (birth)
o Mortality (death) Types of Population Pyramid
o Migration ➢ Expansive Population Pyramid
▪ Emigration: going out of the o depicts population that have larger
country percentage of people in younger age
▪ Immigration: going in or moving group
to a country o usually in the third world countries
- 2 methods of Population Allocation: ➢ Constrictive Population Pyramid
o De Facto Method – people are counted o they are constricted at the bottom
or allocated to the area where they were o lower percentage of younger people
physically present at the time of the o shows declining birth rate
census; usually done in the Philippines o usually in developed nations
o De Jure Method – people are counted or ➢ Stationary Population Pyramid
allocated to the place of their usual o equal proportion of the population and
residence each age group
o stable population
POPULATION COMPOSITION
- Determines the number of percentage of the
POPULATION DISTRIBUTION
population according to the categories of - Description of how people are distributed in a
important sociodemographic economic variables specified space or geographic area:
- The most basic description of the population o Affected by:
composition is according to age and sex. ▪ Physical (geography)
▪ Political (peace and order)
Factors Affecting Population Composition ▪ Social/Cultural (ethnic groups)
▪ Economic (rural to urban)
• Birth rate: no. of births per 1000 population
o Indicators:
• Death rate: no. of deaths per 1000 population ▪ Population density –
• Emigration: number of people leaving a country measurement of population per
• Immigration: number of people moving to a unit area
country ▪ Crowding index – number of
usual residents in a dwelling
Describing the Age Composition of a Population over number of rooms in the
• Median Age: the age below which we have 50% dwelling
of the population
o The lower the median age, the younger
the population
• Age dependency ratio: indicator of age-induced - Computation of future changes in population
economic drain on human resources numbers, given certain assumptions about
o Formula: future trends in the rates of fertility, mortality,
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 15−64 and migration
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 0−14 + 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 ≥65
𝑥 100 - Population Estimation is under demography
o Dependents: Children (0-14yo) and - Purposes of Population Estimates:
Elderly (≥65yo) o For analysis of various trends
o Independents: Computed as the ratio of o For measuring shifts in population
the dependents to the economically o For determining allocation of public
active group (15-64 yrs old) of the funds or political representation in the
population government
o For planning
Describing the Sex Composition of a Population
✓ Sex ratio: computed by dividing the number of MEASURES OF CHANGES IN POPULATION SIZE
males by the number of females using a factor of Natural Increase
100
- Formula: number of births – number of deaths =
natural increase in a specific place and time
- Example: Determine the natural increase in 2017
 BIOSTATISTICS AND EPIDEMIOLOGY

YEAR 2017
Births 1,761,602
METHOD OF ESTIMATION
Deaths 531,280 - Take into account all the operations that can
Computation: 1,761,602 – 531,280 = 1,230,322 affect population size
Interpretation: There are 1,230,322 persons
added to the population in 2017 through natural Component Method
means. - Also known as inflow-outflow or balancing
equation method
Rate of Natural Increase - Formula: Pt = Po + (B – D) + (I – O)
- Formula: crude birth rate (CBR) – crude death o B = births in the interval 0 and t
rate (CDR) = rate of natural increase in a specific o D = deaths in the interval 0 and t
place and time o I = immigration between 0 and t
- natural increase expressed as rate o O = out-migration between 0 and t
- Example: Determine the rate of natural increase
in the year 2017 given the data below. Mathematical Method
YEAR 2017
Population 98,393,574 ➢ Arithmetic method – assumes equal change
Crude Birth Rate 24.4/1000 every year
Crude Death Rate 5.9/1000 ➢ Geometric method – assumes that the
24.4 5.9 18.5 population changes at the same rate over each
Computation: − =
1000 1000 1000 unit
Interpretation: In 2017, 19 for every 1000
➢ Exponential method – assumes a constant rate
persons were added to the population through
of change (r) and population is increasing
natural means.
continuously

Relative Increase Exponential Method Formulas

- Actual difference between 2 census counts ➢ Estimating Rate of Change (r)
expressed in percent relative to the population 𝑃
size of the prior census 𝐼𝑛 (𝑃𝑡 )
0
𝑃𝑡 − 𝑃0 𝑥 100
- Formula: 𝑥 100 𝑡
𝑃0 o Pt = future population
o P0 = population size at an initial time, o P0 = past population
time 0 o t = time elapsed
o Pt = population size at time t ➢ Estimating Future Population (Pt)
𝑃0 𝑒 𝑟𝑡
Absolute Increase per year (b) o P0 = past population
- Measures the average number of people added o t = time elapsed
to the population per year o r = rate of change
𝑃𝑡 − 𝑃0 o e = constant equivalent to 2.71
- Formula:
𝑡 ➢ Estimating Past Population (P0)
o P0 = population size at an initial time, 𝑃𝑡
time 0 𝑒 𝑟𝑡
o Pt = population size at time t o Pt = future population
o t = number of years between time 0 and o e = constant equivalent to 2.71
time t o r = rate of change
o t = time elapsed
Estimating Relative and Absolute Increase ➢ Estimation of the amount of time (t)
YEAR POPULATION 𝑃
2010 92,337,852 𝐼𝑛 (𝑃𝑡 )
0
2013 98,393,574
✓ Compute for Relative Increase from 2010 – 2013 𝑟
o Pt = future population
𝑃𝑡 − 𝑃0
𝑥 100 o P0 = past population
𝑃0 o r = rate of change
(98,393,574) − (92,337,852)
𝑥 100 = 6.56%
92,337,852 Always Remember!
✓ Compute for Absolute Increase per year from • When computing for time that elapsed between
2010 – 2013 past and future censuses:
𝑃𝑡 − 𝑃0 o There are 30 DAYS in a MONTH
𝑡 o There are 365 DAYS in a YEAR
98,393,574 − 92,337,852 o There are 12 MONTHS in a YEAR
= 2,018,574
3
Example:
YEAR 1995 2000
Annual rate of growth (r) Census date September 1, 1995 May 1, 2000
- Also utilize results of 2 censuses to quantify the Population 68,616,538 76,504,077
Live Births 1,766,440 1,645,043
amount of change in population size Deaths 324,737 366,931
- Assumes that the population is changing at a CBR 25.74/1000 21.50/1000
constant rate per year CDR 4.73/1000 4.80/1000
 BIOSTATISTICS AND EPIDEMIOLOGY

Given in the table is the Philippine census information in o Interpretation: There is an estimated
1995 and 2000. Using the data, estimate the following: 11.49 years for the population to reach
✓ Rate of change 100,000,000, assuming a rate of change
o Given: of 2.33%
▪ Pt = 76,504,077
▪ P0 = 68,616,538
▪ t=?
▪ r=?
o Solve for t:
May 1, 2000: 2000 + 5/12 + 1/365
Sep. 1, 1995: 1995 + 9/12 + 1/365
4 + 8/12 + 0/365
t = 4.67 years
o Solve for r:
𝑃 76,504,077
𝐼𝑛 ( 𝑡 ) 𝐼𝑛 ( )
𝑃0 68,616,538
𝑡
𝑥 100 = 4.67
𝑥 100
r = 2.33%
o Interpretation: The population increases
at a constant rate of 2.33% from 1995 to
2000
✓ July 1, 2005 population (Future Population)
o Given:
▪ P0 = 76,504,077
▪ r = 2.33%
▪ t=?
▪ Pt = ?
o Solve for t:
July 1, 2005: 2005 + 7/12 + 1/365
May 1, 2000: 2000 + 5/12 + 1/365
5 + 2/12 + 0/365
t = 5.17 years
o Solve for Pt:
𝑃0 𝑒 𝑟𝑡 = (76,504,077)(𝑒 (0.0233)(5.17) )
Pt = 86,297,881
o Interpretation: There will be 86,297,881
estimated population on July 1, 2005,
assuming a rate of change of 2.33%
✓ December 25, 1997 population (Past
Population)
o Given:
▪ Pt = 76,504,077
▪ r = 2.33%
▪ t=?
▪ P0 = ?
o Solve for t:
May 1, 2000: 2000 + 5/12 + 1/365
Dec 25, 1997: 1997 + 12/12 + 25/365
2 + 4/12 + 6/365
t = 2.35 years
o Solve for P0:
𝑃𝑡 76,504,077
=
𝑒 𝑟𝑡 𝑒 (0.0233)(2.35)
P0 = 72,427,716
o Interpretation: There is 72,427,716
estimated population on December 25,
1997, assuming a rate of change of
2.33%
✓ time to reach 100, 000, 000 population
o Given:
▪ Pt = 100,000,000
▪ P0 = 76,504,077
▪ r = 2.33%
▪ t=?
o Solve for t:
𝑃 100,000,000
𝐼𝑛 ( 𝑡 ) 𝐼𝑛 ( )
𝑃0 76,504,077
=
𝑟 0.0233
t = 11.49 years