To determine whether such an association exists, we

must determine, using data obtained in case-control

and cohort studies, whether there is an excess risk

of the disease in persons who have been exposed to

a certain agent. Let us consider the results of a

hypothetical investigation of a foodborne disease

outbreak. The suspect foods were identified, and for

each food, the attack rate (or incidence rate) of the

disease was calculated for those who ate the food

(exposed) and for those who did not eat the food

(nonexposed), as shown in Table 11-1.

How can we determine whether an excess risk is

associated with each of the food items? One

approach, shown in column C of Table 11-2, is to

calculate the ratio of the attack rate in those who

ate each food to the attack rate in those who did

not eat the food. An alternate approach for identifying

any excess risk in exposed individuals is shown

in column D. We can subtract the risk in those who

did not eat the food from the risk in those who did

eat the food. The difference represents the excess

risk in those who were exposed.

Thus, as seen in this foodborne outbreak, to

determine whether a certain exposure is associated

with a certain disease, we must determine whether

there is an excess risk of disease in exposed populations

by comparing the risk of disease in exposed

populations to the risk of disease in nonexposed

populations. We have just seen that such an excess

risk can be calculated in the two following ways:

1. The ratio of the risks (or of the incidence rates):

Disease risk in exposed

Disease risk in nonexposed

2. The difference in the risks (or in the incidence

rates):

Disease risk

in exposed

Disease risk

in nonexposed

)−-

Does the method that we choose to calculate

excess risk make any difference? Let us consider a

hypothetical example of two communities, A and

B, seen in Table 11-3.

In community A, the incidence of a disease in

exposed persons is 40% and the incidence in nonexposed

persons is 10%. Is there an excess risk associated

with exposure? As in the food poisoning

example, we can calculate the ratio of the rates or

the difference between the rates. The ratio of the

incidence rates is 4.0. If we calculate the difference

in incidence rates, it is 30%. In community B, the

incidence in exposed persons is 90% and the incidence

in nonexposed persons is 60%. If we calculate

the ratio of the incidence of exposed to nonexposed

persons in population B, it is 90/60, or 1.5. If we

calculate the difference in the incidence in exposed

and nonexposed persons in community B it is,

again, 30%.

What do these two measures tell us? Is there a

difference in what we learn from the ratio of the

incidence rates compared to the difference in the

incidence rates? This question is the theme of this

chapter and of Chapter 12.