Step 4: Risk Factor Study in a Defined

Population

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The Basic Idea

Identify exposures that are associated A simple measure of association is the

with a disease relative risk (RR):

These may indicate the source of the

=
disease—or activities that aid in
transmission
If the RR is much greater than one, then
the exposure is highly associated with the
disease

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Calculating an Attack Rate

The attack rate (AR) is calculated as the number of people in a group who developed
disease divided by the total number of people at risk for infection in that group

Groups are commonly defined by:

Individual characteristics (for example, age)
Exposure (for example, drinking milk at lunch)
Location

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 Outbreak in a Defined Population: Prairie Dog Exposure

Attack rate in exposed Prairie dog exposure and clinical monkeypox among
children: childcare attendees
2/6 = 33.3%
Exposed to Number Number
Attack rate in unexposed prairie dog sick not sick Total
children: Yes 2 4 6
2/12= 16.7%
No 2 10 12
Relative risk:
33.3%/16.7% = 2

Source: Kile et al. (2005). Arch Pediatr Adolesc Med. https://doi.org/10.1001/archpedi.159.11.1022 4

 Outbreak in a Defined Population: Drinking Raw Milk

Relative risk is infinite: Raw milk consumptions and campylobacteriosis in

60%/0% = participants in a third grade field trip to a farm

Increasing attack rate with Glasses Number

more consumption provides consumed sick Total AR
additional evidence that milk is 0 0 20 0%
the cause.
1 7 20 35%
This is called a dose-
response relationship 18 30 60%

Source: adapted from Korlath et al. (1985). JID. 5

Key Points Attack rate is the percentage of a group that gets the disease

Relative risk provides a comparison of attack rates between

groups

A relative risk above one indicates that the group in the

numerator has a higher attack rate than the group in the
denominator

This approach only works if exposed and unexposed

populations are identified without regard to their disease
status

This condition is most often fulfilled when there is a clearly

defined at-risk population (for example, students at a school)