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MORBIDITY
MORBIDITY INDICATORS
Definition: all known diseases at a certain moment in time, or during a certain
period of time, in a population from a well-defined territory, whether they were detected
during that specified period on or after it (even at the time of death); whether detection
was made during an earlier period but the disease also exists at present; whether the
illness has been resolved (healing, death) or not during the period to which we refer.
Through international consensus, traumas, accidental or voluntary (homicides,
suicides) poisonings, injuries, and the burnings caused by wars are also associated to
morbidity.
Forms associated with the study of morbidity:
1. General Morbidity
 Incidence
 Prevalence – momentary
- periodical
 Contingent morbidity
 Successive morbidity
 Morbidity associated with temporary incapacity to work
 Morbidity associated with permanent incapacity
 Hospitalized morbidity
Terms used in the study of morbidity:
- Disease or illness: nozologic entity characterized by the alteration of a person’s
health
- Disease or ill person: the notion of disease is not similar to that of diseased/ill
person, since the diseased person can suffer from more than one illness
simultaneously
- clinical case = ill person
- in morbidity = "new case" / "old cases"
Newly detected case = diagnosis on the first medical consultation, when the
case is also registered. The newly detected case may be:
- Clinically new case
- Statistically new case (although the date of falling ill could have been years ago, as
it happens, for example, in the case of chronic diseases)
Old case = already diagnosed and registered case, when the patient returns
to the consultation room for treatment, hospitalization, etc.
 Encoding = form of replacing the text with signs or conditional figures. In
order to establish a common international language, WHO has drawn an
international list of causes of disease and death (the International
Classification). It is based on scientific criteria that are acknowledged
worldwide: etiology, clinical manifestations, anatomical location or mixed.
Periodically this classification is revised, after the meeting of some expert
committees. Currently, the classification is based on the 10th revision, by
WHO, of the International Classification in terms of 1000 causes for illness
and death, from 0 to 999.
 The encoding - new case relationship
The new cases is encoded at the moment of the diagnosis (in the information
system proposed by WHO) and is taken into account for the calculation of incidence.
After healing, if the respective patient falls ill again, the case will be encoded again as a
new case (e.g. the case of acute illnesses).
The old case is encoded only once, at first diagnosis, and is taken into account for
the calculation of prevalence (e.g. chronic diseases).
In the study is morbidity, the WHO desiderate is to include the entire population
in this evaluation and create a relevant information system.
The aims of the WHO information system
• describe the current health-state of the population by means of a passive
information system;
• early onset of the health state evolution with the help of an active information
system;
• forecast tendencies, in order to manage the implementation of optimal and
effective prophylaxis and resource planning, the elaboration of strategies, the assessment
of health-care services, and of the quality of medical acts.
The importance of the informational system: WHO believes that the information
system should be based on data collection through normal administrative channels,
emphasizing the importance of non-institutionalized patients’ consultations (in the
general practitioners' consultation rooms, or those of specialists in outpatient clinics).
When medical care is provided in public dispensaries (medical or specialized), the
statistics of these institutions reflect quite well the overall morbidity of the population.
The data are combined and compared with those recorded in hospital statistics, health
insurance centers and the results of well-organized health surveys.
GENERAL MORBIDITY
Incidence
Definition: the frequency of new cases registered within a given territory and
during a certain time period (month, quarter, year) in medical dispensaries (territorial and
associated to factories).
Since 1987, hospitals and specialists working in outpatient clinics must declare
the new disease cases, confirmed by the statement of declaration / communication of
chronic diseases.
In calculating the incidence, chronic diseases are registered only once, as "new
cases" – at the moment of the diagnosis.
Acute diseases that are healed and then reappear as a new disease, but not as
relapse, are considered again new cases (e.g. flu after two months from the healing the
past episode).
In case of detecting several diseases at the same person, each one of these is
encoded.
Calculating formulas
1. Indices of overall incidence:
bn
It=
x 1000
L
2. Indices of specific incidence (sex, age groups, etc.):
bn(c,x)
Is =
x 100000
Lx
It = index of overall incidence
bn = new identified disease (new case)
L = the average number of inhabitants
c, x = new cases detected with certain diseases, at a certain age
Lx = average number of inhabitants of a certain age
Maximum value: over 10000/00 because a person may have several diseases
Minimum value: it can not be 0 because normally any condition is recorded
Mean values: 400 to 500 0/00 people
Number of new cases with the "X" disease
Morbidity in terms of specific cases =
x100000
Number of inhabitants
- Shows the frequency of new cases of a given disease in a territory and during a certain
period of time
Specific morbidity in relation to causes and age groups
Number of new cases of disease "X", at age "Y"
=
X100000
Number of people of the "Y" age
3. The structure of morbidity
Number of new cases of the "X" disease
=
X100
Total number of diseases
- Shows the frequency of a certain disease in relation to the total number of diseases
- the ranks of morbidity structure are created (as in the case of mortality)
Rank I: respiratory diseases
Rank II: digestive diseases
Rank III: diseases of the nervous system and of the sense organs
Factors that influence the understanding of morbidity:
 accessibility
 addressability
 the quality of medical acts
According to WHO, if availability, addressability and the quality of medical acts
are optimal, it means that the percentage that remains unknown after studying incidence
is of 25% or 10%.
It is important that all data should are recorded in the unique medical sheets, for
the actual knowledge of the population’s health-state and in order to increase the quality
of the medical care provided.
Prevalence
Definition: all diseases that exist at a particular "critical" moment 1 (the last day
of the trimester, semester, year) or in a particular period 2 (trimester, semester, year).
1time prevalence
2 period prevalence
Prevalence is calculated separately, in relation to different diseases; in case of chronic
diseases = all old and new cases of disease.
Calculating formulas:
bn + bv
Pr. =
x 100
L
bn (x) + bv (x)
Pr (x)=
x 100 or 100000
L (x)
Pr şi Pr (x) = index of overall prevalence and in relation to age
bn, bv = new diseases discovered, previously unknown diseases (old)
bn (x), bv (x)= new diseases discovered, previously known diseases, at certain ages
L, Lx = average number of inhabitants, average number of inhabitants of certain ages
Prevalence is studied because incidence may present very high variations at
different moments and in relation to different causes:
 "false alarm"
 "fake calming"
It is therefore important to calculate the trend that eliminates these random
variations.
In order to get the value of prevalence, various sources (consultations, complex
medical investigations, reporting, etc.) are combined.
TBC
Fact?
False alarm?
Fact?
False calm?
Successive morbidity
The successive morbidity can be evaluated with the help of the health
investigation technique.
Through the longitudinal study, which is applied successively in time, causality
links can be established between the occurrence, worsening of complications, the more
frequent association and concomitance of diseases, as well as the registration of those
categories of persons who remain healthy year after year (it can study potential protective
factors).
Successive morbidity enables the evaluation of the medical activity for the
prevention of morbidity, including the identification of failure in prevention programs.
Successive morbidity ensures a scientific evaluation of the situation, using data
gathered by the doctor and not the patient, thus eliminating errors in the assessment of
anamnestic data.
Thus, illnesses that appear successively at the same groups of persons can be
monitored year after year, as well as the associations of more common diseases, the
implications of some conditions in the emergence of chronic disease, etc. Successive
morbidity does not study retrospectively the patient history, but seeks successive
historical sequence of events leading to disease.
Successive morbidity is the study of new cases detected in a year and the study of
aggravations (acute, relapse) of previously detected chronic diseases.
Successive morbidity allows the dynamic evaluation of morbidity by sex, cause,
age groups, thus being possible to make accurate comparisons between regions, areas
with different age group structures, without the need of standardization.
Successive morbidity allows a longitudinal section of the population morbidity in
relation to categories of healthy and sick persons. As it takes into account exacerbations
(aggravations) in chronic diseases – in relation to causes, sex, age groups, environments,
etc.. - and data about persons who have not presented a worsening of their condition
during that year - by gender, age group, environments – it helps achieve a complete and
comprehensive study on population morbidity.
Successive morbidity allows the identification of the number of people healed, or
having fallen ill (from the healthy population), or of the number of diseases, those with
one, two, three diseases, have additionally contacted, the number of deaths, etc.
Morbidity in relation to contingents
The survey regarding the health state also allows the study of morbidity in
relation to contingents, i.e. the proportion of ill people in a specific community and the
number of diseases each patient suffers from.
Contingent/number = people actually selected on the basis of common
characteristics (age, gender, occupation, environment of origin, etc.).
For Public Health and Management, the study on contingents allows the
evaluation of the populations’ health state and can be subdivided into:
 Healthy
– with risk factors
– without risk factors
 Ill persons
– with risk factors
– without risk factors
- with one, two or several diseases
In urban regions, morbidity in relation to contingents (numbers) on quotas is
higher than in rural areas and higher in the female sex.
In relation to the age group of people between 30-34 years, the morbidity index in
relation to contingents corresponds to the country average index.
The indices obtained generally describe a curve similar to that of the morbidity
prevalence, though at a lower level. The differences are smaller between 0-24 years and
are becoming higher as the age progresses.
In relation to environments, the distribution of contingent morbidity by age
groups describes a curve similar to that referring to the urban environment - but at a
higher level. At 0-14 years, the urban indices are lower that those in rural areas. From 15
years upwards, in case of all age groups, the values registered in urban areas are higher as
compared to those obtained in rural areas.
At women, supra-morbidity can be recorded at all age groups, except for groups
between 0-9 years and over 80 years. Minimal indices are recorded in the group of 15-19
years, and the values are lower in the case of males. Maximum indices are recorded at
men at ages over 80 years, and at the women belonging to the 74-79 years group.
The efficiency of the preventive or the curative measures applied will be checked
with the help of the longitudinal studies of successive morbidity.
Morbidity by age groups
The incidence of morbidity is different in relation to age groups. The knowledge
of trends allows the adjustment of health care services (preventive actions, material,
human, time, financial, etc. resources).
Incidence
0
1 year
4 years
14 years
30-40 years
60
years
Morbidity causes:
0-1 year - perinatal conditions
- Respiratory diseases
- Diseases of the digestive system
- Infectious and parasitic diseases
1-14 years - respiratory diseases
- Diseases of the digestive system
- Accidents
- Infectious and contagious diseases
14 years – the "Golden age"
15-19 years – minimal indices
20-60 years - acute respiratory and digestive diseases
- Chronic diseases
- Occupational diseases
From 30-40 years, the contingent-related morbidity index is consistent with the average
index for the country;
60 years and over - chronic diseases
Morbidity by gender
There is a female supra-morbidity at all age groups, except for the 1-9 years and
over 80 years age groups (through successive contingent-related morbidity).
Possible explanations
• the greater vulnerability of the female sex
• genital pathology
Iuliu Hatieganu described the so-called "dextritis" – disorders of the right ovary,
of the gallbladder, of the appendix, but women actually have a higher level of medical
culture, which makes them more aware of health-related risks and, given their multiple
roles in the family, they present a higher addressability to health services.
Morbidity by environments
Contingent morbidity is higher in urban, as compared to rural areas.
In terms of age-groups, a curve similar to that of the set environment can be observed,
though it registers a higher level in the urban environment.
For the 0-14 years age-group, the indices in the urban environment are lower than in
the rural environment.
From 15 years on, higher values are registered in urban areas. This increase is
apparent because:
 Addressability and accessibility are higher in the urban environment
 The quality of medical acts is higher in urban areas
 The level of culture and education for health is higher in the urban
environment
 The registration and report of cases is better in urban areas
The transition of morbidity
Morbidity transition is secondary to demographic transition, being one of its
consequences, but also related to the economic and social development.
The phenomenon is placed between the two types of morbidity and mortality:
 primitive
 evolved
“Primitive” morbidity
 endemic: infectious, parasitic diseases, acute digestive diseases;
 Characteristic to underdeveloped countries, where a high-frequency of
chronic diseases is also encountered.
Morbidity of the “evolved” type
 High prevalence of chronic diseases: hypertension, ischemic heart disease,
chronic pulmonary heart, digestive or renal chronic diseases, diabetes, etc.
 Characteristic of economically and socially developed countries,
associated with the increase in the percentage of elderly people
“Intermediary” morbidity, or morbidity of the intermediary type - characteristic of
developing countries, which present a decreasing infectious pathology and an increasing
chronic pathology.