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# Lesson 3: Measures of Risk

## Section 6: Measures of Public Health Impact

A measure of public health impact is used to place the association between an exposure and an outcome into a meaningful public health context. Whereas a measure of association quantifies the relationship between exposure and disease, and thus begins to provide insight into causal relationships, measures of public health impact reflect the burden that an exposure contributes to the frequency of disease in the population. Two measures of public health impact often used are the attributable proportion and efficacy or effectiveness.

### Attributable proportion

#### Definition of attributable proportion

The attributable proportion, also known as the attributable risk percent, is a measure of the public health impact of a causative factor. The calculation of this measure assumes that the occurrence of disease in the unexposed group represents the baseline or expected risk for that disease. It further assumes that if the risk of disease in the exposed group is higher than the risk in the unexposed group, the difference can be attributed to the exposure. Thus, the attributable proportion is the amount of disease in the exposed group attributable to the exposure. It represents the expected reduction in disease if the exposure could be removed (or never existed).

Appropriate use of attributable proportion depends on a single risk factor being responsible for a condition. When multiple risk factors may interact (e.g., physical activity and age or health status), this measure may not be appropriate.

#### Method for calculating attributable proportion

Attributable proportion is calculated as follows:

Attributable proportion can be calculated for rates in the same way.

#### EXAMPLE: Calculating Attributable Proportion

In another study of smoking and lung cancer, the lung cancer mortality rate among nonsmokers was 0.07 per 1,000 persons per year.(*14*) The lung cancer mortality rate among persons who smoked 1–14 cigarettes per day was 0.57 lung cancer deaths per 1,000 persons per year. Calculate the attributable proportion.

Attributable proportion = (0.57 − 0.07) ⁄ 0.57 × 100% = 87.7%

Given the proven causal relationship between cigarette smoking and lung cancer, and assuming that the groups are comparable in all other ways, one could say that about 88% of the lung cancer among smokers of 1 14 cigarettes per day might be attributable to their smoking. The remaining 12% of the lung cancer cases in this group would have occurred anyway.

### Vaccine efficacy or vaccine effectiveness

Vaccine efficacy and vaccine effectiveness measure the proportionate reduction in cases among vaccinated persons. Vaccine efficacy is used when a study is carried out under ideal conditions, for example, during a clinical trial. Vaccine effectiveness is used when a study is carried out under typical field (that is, less than perfectly controlled) conditions.

Vaccine efficacy/effectiveness (VE) is measured by calculating the risk of disease among vaccinated and unvaccinated persons and determining the percentage reduction in risk of disease among vaccinated persons relative to unvaccinated persons. The greater the percentage reduction of illness in the vaccinated group, the greater the vaccine efficacy/effectiveness. The basic formula is written as:

OR: * 1 − risk ratio*

In the first formula, the numerator (risk among unvaccinated − risk among vaccinated) is sometimes called the risk difference or excess risk.

Vaccine efficacy/effectiveness is interpreted as the proportionate reduction in disease among the vaccinated group. So a VE of 90% indicates a 90% reduction in disease occurrence among the vaccinated group, or a 90% reduction from the number of cases you would expect if they have not been vaccinated.

#### EXAMPLE: Calculating Vaccine Effectiveness

Calculate the vaccine effectiveness from the varicella data in Table 3.13.

VE = (42.9 − 11.8) ⁄ 42.9 = 31.1 ⁄ 42.9 = 72%

Alternatively, VE = 1 − RR = 1 − 0.28 = 72%

So, the vaccinated group experienced 72% fewer varicella cases than they would have if they had not been vaccinated.

## References (This Section)

- Doll R, Hill AB. Smoking and carcinoma of the lung. Br Med J 1950;1:739–48.