Screening for Disease

Learning Objectives

At the end of the session, the student would be able to

 Define Screening
 Explain the Need / Concept of Screening
 List the Uses of Screening
 State the different types of Screening
 List the Criteria for Screening
 Explain Sensitivity & Specificity
 List some common Screening tests
 What is Screening?

 The search for unrecognized disease or

defect by means of rapidly applied tests,
in apparently healthy individuals.

Compare with a diagnostic test

 Why Screening ?

 Its been long recognized by epidemiologists that the

pattern of disease in hospitals is very different from
that in a community.

Subclinical cases, undiagnosed cases, carriers

 Concept of screening
Active search for disease among apparently healthy
people is a fundamental aspect of prevention

Historically – annual health examinations.

 Reach masses
 Conserve physician-time (technicians can apply)
 Simple, inexpensive lab tests

specific diseases – Tuberculosis, syphilis

specific groups – AN mothers, school children, Occup
Grps
 Common Screening tests

 Pregnancy – Anemia, hypertension and Rh status,

toxemia, syphilis
 Infancy – Cerebral palsy, Hearing and visual defects,
haemoglobinopathies
 Middle aged woman – Hypertension, cancer and
diabetes
 Elderly – Nutritional disorders, Cancer, Glaucoma and
cataract
 Concept of Lead Time
Disease First Final Usual
Onset Possible Critical Time of OUTCOME
point diagnosis diagnosis
A

Screening Time B

Lead Time
 Uses of Screening
 Case Detection

 Control of Disease

 Research purpose

 Educational Opportunities
 Types of Screening

Mass screening

High-risk or selective screening

Multiphasic screening
 Criteria for Screening
Disease Test
! Important health problem
! Recognizable latent or early asymptomatic phase
! Natural h/o understood
! A test to detect the disease prior to onset of signs
! Facility to confirm diagnosis
! Effective treatment available
! Agreed-on policy on whom to treat (cut-offs)
! Evidence that early Dx&Rx reduces morbidity/mortality
 Criteria for Screening
Test
! Acceptability
! Repeatability (Reliability or reproducibility)
a. Observer – Intra-observer / Inter-observer variation
b. Biological (subject) variation
c. Technical errors from instruments

! Validity (accuracy)
a. sensitivity b.specificity c. predictive value
 Sensitivity & Specificity
GOLD STANDARD
Diseased Non-Diseased
Screening Test results

Positive a (True positive) b (false positive)

Negative c (false negative) d (True negative)

 Sensitivity & Specificity
TRUTH
Guilty Not Guilty

Guilty a b
VERDICT

c d
Not Guilty
 Acceptability

 It is important that the test should be acceptable to

people at whom it is aimed.

 Tests that are painful, discomforting or embarrassing

are not acceptable to the population.
 Repeatability

 The test must give consistent results when repeated

more than once on the same individual or material
under the same conditions.

 It depends on three major factors namely the

observer variation, biological variation and the
errors relating to technical methods.
 Validity

 Refers to what extent the test accurately measures which

it purports to measure or it is the ability to distinguish
those who have the disease from those who do not.
E.g. – GTT

 It has 2 components – sensitivity and specificity.

 Sensitivity, specificity and predictive accuracy are the

inherent properties of a screening test
 Sensitivity

 Defined as the ability of the test to identify correctly

all those who have the disease, that is the true
positives

 90% sensitivity – 90% of the diseased people screened

by the test will give a true positive
 Specificity

 Defined as the ability to identify correctly who do not

have the disease, that is true negatives

 90% of the specificity – 90% of the non diseased

persons will give true negative results

 10% of the people will be wrongly classified as

diseased
Cut-offs values and the problem of
borderlines

 In case of diagnostic tests that yield a quantitative

result, there will be an overlapping of the
distributions of an attribute for diseased and non
diseased persons

 False positives and false negatives comprise the area

of overlap
 Predictive Accuracy

 The predictive value of a positive test indicates the

probability that a patient with a positive result has in
fact, the disease in question

 The more prevalent a disease is in a given population,

more is the accuracy of the predictive value
 False Negatives

 False negatives mean that patients who actually have

the disease are told that they do not have the disease

 This could be detrimental if the disease is a serious

one and the screening test is unlikely to be repeated
in a short period of time

 High sensitivity tests have few false negatives

 False Positives

 False positives mean that patients who do not have

the disease are told that they have

 A screening test with a high specificity will have few

false positives

 False positives bring discredit to the screening

programmes
 Evaluation of screening test
 Sensitivity a/a+c
 Specificity d/b+d
 PPV a/a+b
 NPV d/c+d
 False Negative % c / a + c
 False Positive % b / b + d
 Yield

 Yield is the amount of previously unrecognized

disease that is diagnosed as a result of screening
effort

 E.g., By limiting a diabetes screening programme to

persons over 40 years, you can increase the yield of
the screening test
 Combination of Tests

 Two or more tests can be used in combination to

enhance the specificity or sensitivity of screening

 E.g. Syphilis
 At the end of the session, the student would be able to

 Define Screening
 Explain the Need / Concept of Screening
 List the Uses of Screening
 State the different types of Screening
 List the Criteria for Screening
 Explain Sensitivity & Specificity
 List some common Screening tests
The End