ESTIMATING RISK

(ATTRIBUTABLE RISK)
Dr. Waqar Ali
HoD, Community Medicine
Vice Principal Research
PhD Scholar, MBBS, MPH, MNCH, QMIH (Germany),HRHM (U.K)
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Museum Presentations
Recall
• When and why do we use Relative Risk & Odd Ratio?
• Provides an increase or decrease in the
likelihood of an event based on some exposure.
A lower risk of symptomatic COVID-19 was observed with
vaccination compared to placebo, relative risk [RR] 0.03, 95%
confidence interval [CI]: 0.00, 0.49
Quiz
• A hospital director was getting reports of increasing incidence of
hepatis B in patients receiving blood transfusion from his blood bank
after which he decided to conduct a research. The result showed that
in a one year follow up period 75 out of 500 patients who had
received blood transfusion & 16 of the 700 patents who had not
received transfusion developed hepatis B.
Objectives
• By the end of the session the learner would be able to :

• Understand and calculate Attributable Risk

• Understand and calculate Population Attributable Risk
ATTRIBUTABLE RISK
• How much of the disease that occurs can be attributed (associated) to
a certain exposure?

• This is answered by another measure of risk, the attributable risk,

• For example, how much of the lung cancer risk experienced by

smokers can be associated to smoking?
Continue..
• We can calculate

• (1) The attributable risk for exposed persons

• (2) The attributable risk for the total population

(1) Attributable Risk for the Exposed
Group

Question arises?
In the exposed persons, how much of the total risk of disease is
actually due to exposure (e.g., in a group of smokers, how much of
the risk of lung cancer is due to smoking)?
 How Can This Question Be Answered?

Although non exposed persons are not exposed, they have

some risk of disease but the risk of the disease is not zero.

E.g., in case of smoking and lung cancer, even non-smokers

have some of lung cancer, possibly due to environmental
chemical carcinogens or other factors.

This risk is termed background risk.

Both non-exposed and exposed persons have this background

risk.
Continue..

OR
Risk in Exposed and Non-Exposed Groups
Example: Cohort Study*

Attributable Risk in Smokers ?

Proportion Attributable Risk in Smokers?

Attributable Risk in Smokers

Interpretation:
Attributable risk indicates the potential for prevention if the
The excess risk to exposure
Coronary could
Heart be
Disease attributable
eliminated. to cigarette
smoking is 10.6/1000/year
Proportion Attributable Risk in Smokers

Interpretation
The proportion of Coronary Heart Disease in cigarette
smokers attributable to smoking is 37.9%
Quiz
• To determine the association between thalassemia in offspring and
consanguinity, 50 thalassaemic children from a hospital and 50 non
thalassaemic children of the same age, coming to the hospital for other
ailment were enrolled. Information about their parents being family
relative or not was obtained from mothers using structured
questionnaire. 18% of parents of thalassaemic children were family
relatives where as 8% of non thalassaemic were family relatives.
POPULATION ATTRIBUTABLE RISK
(2) Attributable Risk for the Total Population—
Population Attributable Risk (PAR)*

• Assume that we know how to eliminate smoking.

• Minister asks “What will the impact of your smoking cessation

program be on lung cancer incidence rates in our city?”

• Population that is composed of both smokers and nonsmokers.

Continue..
• To answer the minister's question as to what effect the smoking
cessation program will have on the city's population as a whole.

• We need to calculate the attributable risk in the total population

Attributable Risk in the Total Population
Attributable Risk in the Total Population (Smoking
& Lung cancer)
Attributable Risk in the Total Population
• To calculate, we must know either the incidence of the disease (CHD) in the total
population (which we often do not know) or

• All of the following three values, from which we can then calculate the incidence
in the total population:

− Incidence among smokers

− Incidence among nonsmokers
− Proportion of the total population that smokes
Attributable Risk in the Total Population-
Example

In this example:
• The incidence in smokers = 28.0/1,000/year
• The incidence in nonsmokers = 17.4/1,000/year

From another source, we learn that:

• The proportion of smokers in the population is 44%.
So, we know that:
• The proportion of nonsmokers in the population is 56%.
Attributable Risk in the Total Population*
The incidence in smokers = 28.0/1,000/year
The incidence in nonsmokers = 17.4/1,000/year
The proportion of smokers in the population is 44%.
The proportion of nonsmokers in the population is 56%.

(Just The 1st Part Of Formula)

?
Attributable Risk in the Total Population

?
Attributable Risk in the Total Population

Proportion of incidence attributable to exposure

Interpretation:
?
The excess risk to Coronary Heart Disease attributable to
cigarette smoking is 21.3% in total population
Attributable risk is a critical concept particularly in relation to
questions regarding the potential of preventive measures.

The authors reported that tobacco and

diet-activity patterns accounted for 33%
of all deaths.
Epidemiology of Traumatic Head Injury
• In recent research, falls have been identified as the main cause of
traumatic head injury (proportion attributable risk increased from
43% to 54% between 2003 and 2012),

• followed by road traffic accidents (proportion attributable risk

dropped from 39% in 2003 to 24% in 2012), violence, sports-related
injuries, and work-related injuries. 
COMPARISON OF RELATIVE RISK AND
ATTRIBUTABLE RISK

• Relative risk is valuable in etiologic studies of disease, whereas the

attributable risk has major applications in clinical practice and public
health.
Ask any 2 questions
Homework on Edmodo

34
Reference
• Leon Gordis 6th Edition
• K Parks 24th Edition

35
Quiz

Result of Gene X-pert test Tuberculosis + Tuberculosis - Total

Positive 180 30 210

Negative 20 170 190
Total 200 200 400

Calculate sensitivity, specificity, positive and negative

predictive value
THANK YOU