Screening

Dr. Win Khaing, PhD

Associate Professor
Department of Preventive and Social
Medicine, University of Medicine,
Mandalay.
Spectrum of Health

Positive Health
Better Health
Freedom from sickness

Unrecognized sickness
Mild Sickness
Severe sickness
Death
Natural History of a disease
Iceberg Phenomenon of
Disease

Hidden mass of
disease
Eg. Subclinical cases,
carriers, undiagnosed
case.
Prevention
Active search for disease among
apparently healthy people is a
fundamental aspect of prevention.
What is Screening ?
Screening
Screening is the process by which
unrecognized diseases or defects are
identified by tests that can be applied rapidly
on a large scale
It consider a preventive care function
It consider a extension of health care
Explanation of TERM

Screening

Case Finding
Diagnostic tests
Screening vs Diagnostic test
Screening Diagnostic test
Done on apparently Done on those with
healthy indications or sick
Applied to groups Applied to single patients,
all diseases are
considered.
Test result are arbitrary Diagnosis is not final but
and final modified in light of new
evidence, diagnosis is the
sum of all evidence
Screening vs Diagnostic test
Screening Diagnostic test
Based on one criterion or Based on evaluation of a
cur-off point (e.g. number of symptoms,
diabetes) signs and laboratory
findings
Less accurate More accurate
Less expensive More expensive
Not a basis for treatment Used as a basic for
treatment
The initiative comes from The initiative comes from
the investigator or agency a patient with a complaint.
providing care.
Screening vs Periodic health
Examination
In the following respects :
Capable of wide application
Relatively inexpensive

Requires little physician-time

Physician is not required to administer
the test, but only to interpret it.
 Some Screening Tests
Pregnancy Middle-aged men and
Anaemia women
Hypertension Toxemia Hypertension

Rh Status Cancer

Syphilis (VDRL Test) DM

Diabetes Serum cholesterol

Cardiovascular disease Obesity

Neural tube Defects

Downs Syndrome

HIV
 Some Screening Tests
Infancy Elderly
Congenital heart disease Nutritional disorder
Spina bifida Cancer
Cerebral palsy Tuberculosis
Hearing defects Chronic bronchitis
Visual defects Glaucoma
Sickle cell anemia Cataract
Undescended testis

Haemoglobinopathies

Hypothyroidism
Concept of Lead Time
Concept of Lead Time
Lead Time
The interval between the time the disease
can be first diagnosed by screening and that
when it is usually diagnosed in patients
presenting with symptoms.
Lead time is the amount of time gained by
earlier detection of a disease by screening
than by later detection with the appearance of
symptoms.
Lead Time
Long Lead Time Noise Induced Hearing
Loss
Short Lead Time Pancreatic Cancer
Lead time is the advantage gained by
screening. i.e. the period between usual time
of diagnosis by early detection and diagnosis
by other means.
 Detection programme should therefore
concentrate on those conditions where
the time lag between the diseases onset
and it final critical point is sufficiently long
to be suitable for population screening.

Disease First Final Usual

onset possible critical time of
detection point diagnosis diagnosis

B
Screening Time

Lead Time
Biases specific to screening that can lead
to an overestimation of the benefits of
screening

Lead Time Bias

Length Time Bias

Lead Time Bias
Lead Time Bias
Despite person A being diagnosed with
disease earlier than person B, they both die
at the same time. Thus, no decrease in
mortality was gained by person A, only the
length of time during which he knew he was
sick was increased. Time with disease is
extended which leads to the false impression
that early detection improves total survival
Length Time Bias
Length Time Bias
Slowly progressing tumors have more opportunity than faster
ones to be detected by screening. In addition, slowly progressive
tumors take longer to lead to death than faster ones. Therefore,
the screen detected cancers will appear to have an increased
survival after diagnosis, giving the mistaken impression that
screening leads to improved survival.
In reality, the improved survival is a result of these cancers being
more slowly progressing. Thus, the survival rate of a group of
people with screen-detected cancers will be artificially increased
due to length time bias compared with the survival rate of those
with non screen-detected cancers.
 Aims
to sort out from a large group of apparently
healthy persons those likely to have the
disease or at increased risk of disease under
study,
to bring those who are apparently abnormal
under medical supervision and treatment.
in the hope that earlier diagnosis and
subsequent treatment may alter the natural
history of disease in a significant proportion
of those who are identified as positives.
Objectives
Detection of hidden cases in community
Early diagnosis and Prompt Treatment
To reduce the Morbidity, Mortality, etc.
To cure (or) to prolong life
To change the life style
To change the population
Uses of Screening

Case Detection (Prescriptive screening)

Control of disease (Prospective screening)

Research purposes

Educational opportunities
Types of Screening

Mass screening

High risk or selective screening (Targeted

screening)

Multiple or multiphasic screening

Opportunistic screening
Criteria for Screening
Before a screening program is initiated, a decision
must be made whether it is worthwhile
Resources
Ethical
Scientific
Possible financial justification
Based on TWO consideration
DISEASE
TEST
DISEASE
should be an important health problem (high
prevalence)
should be a recognizable latent or early
asymptomatic stage
natural history of the disease should be
adequately understood
There is a test that can detect the disease
prior to the onset of signs and symptoms.
DISEASE
Facilities should be available for
confirmation of the diagnosis.
There is an effective treatment.
There should be an agreed-on policy
concerning whom to treat as patients
There is good evidence that early detection
and treatment reduces morbidity and
mortality.
The expected benefit of early detection
exceed the risks and costs
TEST
Simple
Safe
Cheap
Rapid
Easy to administration
Satisfy the following criteria
Acceptability
Repeatability
Validity (Accuracy)
Acceptability
For higher rate of co-operation,
Test should be acceptable to the people
Test should not be
Painful
Discomforting
Embarrassing
Repeatability
Sometimes called reliability, precision or
reproducibility
Test must give consistent results when
repeated
Depends on 3 major factors
Observer variation
Biological (subject) variation
Errors relating to technical methods