Dampak

Faktor Risiko
 Tujuan
• Bagaimana mengukur dampak
• Ukuran attributable risk
- di antara yang terpapar
- di populasi
 Scenario
• Setelah pengaspalan jalan, kecelakaan lalu
lintas meningkat
• Menurunkan kecelakaan lalulintas?
• Anggaran terbatas
• Hasil penelitian:
Relative Risk
Driving too fast 5
Driving while drunk 10.7
 RR = 5.0

0.000005 0.5
0.000001 0.1

What % are
exposed?
 Ukuran Dampak
• Informasi tentang dampak paparan terhadap
kesehatan masyarakat
• Kontribusi paparan terhadap kejadian penyakit
• Konsep-konsep:
- Attributable risk among exposed
- Preventable fraction among exposed
- Attributable risk in the population
Attributable risk among exposed
(AR)
 Attributable Risk (AR)

• Quantifies disease burden in exposed group

attributable to exposure
• Provides answers to
- what is the risk attributed to the exposure?
- what is the excess risk due to the
exposure?
• Does not make sense in the absence of
causality
• Expressed as risk difference (RD)
among exposed
Attributable Risk (AR)

Iexposed – Iunexposed

among exposed
I = Incidence
 AR Speeding

Outcome

Dead Alive
Speeding

Yes 100 1900 2000

No 80 7920 8000

180 9820 10000

among exposed
 AR Speeding

Outcome

Risk Risk
Dead Alive Risk
Ratio Difference
Speeding

Yes 100 1900 2000 0.05

5 0.04
No 80 7920 8000 0.01

180 9820 10000

among exposed
 AR Drunk driving

Outcome

Dead Alive

Yes 45 255 300

Driving
Drunk

No 135 9565 9700

180 9820 10000

among exposed
 AR Drunk driving

Outcome

Risk Risk
Dead Alive Risk
Ratio Difference

Yes 45 255 300 0.15

Driving
Drunk

11 0.14
No 135 9565 9700 0.01

180 9820 10000

among exposed
 Attributable Risk Percent (AR%)
(synonyms: Attributable Fraction)

• Attributable risk expressed as a percentage of

risk in exposed population
• Proportion of disease among the exposed
which …
- can be attributed to the exposure?
- could be prevented by eliminating the
exposure?

• NOT the etiologic fraction (yet)

among exposed
 Attributable Risk Percent (AR%)

% Iexposed - Iunexposed RR - 1
Iexposed

RR
x 100

Among exposed I = Incidence

 AR% Speeding drivers

Outcome

Dead Alive Risk AR%

Speeding

Yes 100 1900 2000 0.05

0.05-0.01
= 80%
0.05
No 80 7920 8000 0.01

180 9820 10000

Among exposed
 AR% Drunk drivers

Outcome

Dead Alive Risk AR%

Yes 45 255 300 0.15

Driving
Drunk

0.15-0.01
= 93%
0.15
No 135 9565 9700 0.01

180 9820 10000

Among exposed
 AR & AR% dalam
Case-Control Studies
• No direct risk estimates
in case-control study
- AR (risk difference)
and AR% calculation IMPOSSIBLE!

• If odds ratio
approximates relative risk, then

OR - 1
AR%  x 100
OR
Among exposed
Preventable fraction among exposed
(PF)
 Preventable fraction (PF)

• Exposure associated with decreased risk

• Where RR < 1.0, exposure is protective

• Proportion of cases that would have occurred

if exposure hadn’t happened

• Vaccination!
among exposed
Preventable fraction (PF)

Iunexposed - Iexposed
 1 RR
Iunexposed

among exposed
I = Incidence
 Preventable Fraction (PF)
Vaccine efficacy
Cases
Pop. Cases RR
/1000
Vaccinated 301,545 150 0.49 0.3

Unvaccinated 298,655 515 1.72 Ref (=1)

Total 600,200 665 1.11

Iunexposed - Iexposed 1.72 - 0.49

PF   0.72
Iunexposed 1.72

 1 - 0.28  0.72
Among exposed
 Preventable Fraction (PF)
Vaccine efficacy
• Expected number of cases in vaccinated if
unvaccinated

•
1.72 x 301 545 = 519
1 000

• Observed number of cases: = 150

• Estimated number of cases prevented:
= 369 (72%)

Among exposed
Population Attributable Risk
(PAR%)
 Population Attributable Risk (PAR%)

• Proportion of cases in the population

attributable to the exposure
• Proportion of disease in the population that
could be prevented if eliminate risk factor
• Determine exposures relevant to public health
in community
• Does not make sense in the absence of
causality

Among population
 Population Attributable Risk (PAR%)

% Ipopulation - Iunexposed
x 100
Ipopulation

Among population I = Incidence

 Population Attributable Fraction
(PAR%)

PAR% = Ipopulation - Iunexposed x 100

Ipopulation

Among population
 Population Attributable Fraction
(PAR%)
Ipopulation - Iunexposed
PAR% = x 100
Ipopulation

P (RR - 1)
PAR% = x 100
P (RR - 1) + 1
Where P = proportion population exposed

Among population
 Population Attributable Fraction
(PAR%)
Ipopulation - Iunexposed
PAR% = x 100
Ipopulation

P (RR - 1)
PAR% = x 100
P (RR - 1) + 1
Where P = proportion population exposed

PAR% = Pcases (AR) x 100

Where Pcases = proportion cases exposed

Among population
 PAR% Speeding

Outcome

Dead Alive Risk

Speeding

Yes 100 1900 2000 0.050

No 80 7920 8000 0.010

180 9820 10000 0.018

0.018 – 0.010
PAR% = x 100 = 44%
0.018
Among population
 PAR% Drunk driving

Outcome

Dead Alive Risk

Yes 45 255 300 0.150

Driving
Drunk

No 135 9565 9700 0.014

180 9820 10000 0.018

0.018 – 0.014
PAR% = x 100 = 22%
0.018
Among population
 Conclusions

• Driving related deaths in population

- 44% presumably due to speeding
- 22% presumably due to drunk driving

Among population
PAR%: Risk Factors for Cervical Cancer,
USA and Italy

USA Italy
Multiple sexual partners 32% 12%

1st sexual intercourse < 22 yrs 37% 22%

Multiparity 24% 43%

Use of oral contraceptive 9% 5%
Smoker 20% 17%
Irregular screening 46% 84%

Parazzini et al. 1990

 PAR% in Case Control Studies

• proportion of controls exposed

≈ proportion of population exposed
Pcontrols – (OR – 1)
PAR% = x 100
Pcontrols (OR – 1) + 1
Pcontrols = Proportion of controls exposed

OR – 1
PAR% = Pcases ( OR ) x 100
Where Pcases = proportion cases exposed

Among population
 Summary

• Among exposed
- Attributable Risk (AR)
- Attributable Risk percent (AR%)
- Preventable Fraction (PF)

• In the population
- Population Attributable Risk (%)
 Summary

Speeding Drunk driving

Relative risk 5 10.7
Risk difference (%) 4 13.6
AR% 80 91
% drivers with risk 20 3
PAR% 44 22

Where will you put your money

to have the greatest impact on reducing
automobile-related deaths?
 PAR: dependence on prevalence of
exposure and relative risk

100
RR=10
Population AR (%)

80 RR=5

RR=3
60
RR=2

40

20

0
0 20 40 60 80 100
Exposure prevalence (%)

For all values of the relative risk, the population AR increased

markedly as the exposure prevalence increases.
 Ipopulation - Iunexposed
PAR% 
Ipopulation
I population = Pe(Iexposed) + (1-Pe)Iunexposed

Pe (Iexposed )  (1 - Pe)Iunexposed - Iunexposed


Pe (Iexposed )  (1 - Pe)Iunexposed
Divide numerator and denominator by Iunexposed

P (RR - 1)
PAR%  x 100
P (RR - 1)  1