Screening

In Public Health
Practice
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 Unit objectives
 Define screening

 Identify diseases appropriate for screening

 Know the mechanisms of determining the validity of

screening test

 Discuss the criteria for establishing screening program.

 Describe how to evaluate screening program

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 Prevention and Screening
 The majority of cancers are preventable.
 The goal of primary prevention is to avoid the
development of cancer by reducing or eliminating exposure
to cancer-causing factors.
 Secondary prevention aims at early detection at a stage
when curative treatment is still possible. This is achieved by
frequent medical check-ups of individuals or by population-
based screening programs to which all those belonging to a
certain age group are invited.
 Example: Cervical cancer screening in Ethiopia

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 What is Screening?
 Screening is the testing of apparently healthy

populations to identify previously undiagnosed

diseases or people at high risk of developing a disease.

 It is the early detection
– of disease,
– precursors to disease, or
– susceptibility to disease
In individuals who do not show any signs of the disease

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 What is screening?
 It is the search for unrecognized disease or defect by means of
 rapidly applied tests,
 examination or
 other procedures
in apparently healthy individuals.

 Screening aims to detect early disease before it becomes

symptomatic.

 Screening is an important aspect of prevention, but not all

diseases are suitable for screening.

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 Clinical aims of Screening
 To reduce morbidity and mortality through early detection
and treatment
 Is to prevent, interrupt, or delay the development of
advanced disease in the subset with a pre-clinical form of the
target disease through early detection and treatment.

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 Public Health aim of Screening

 Protect society from contagious disease

 Reduce mortality
 Rational allocation of resources
 Research: study on natural history of disease…
Other Use:
 Selection of healthy individuals: employment, military,
driving license …

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 Diagnostic and Screening tests
 Screening tests can also often be used as diagnostic tests.
 Diagnosis involves confirmation of presence or absence of disease
in someone suspected of or at risk for disease.
 Screening is generally done among individuals who are not
suspected of having disease.
 Diagnostic and screening tests are useful for decision to initiate
or continue a therapeutic (preventive) intervention.
➢ Screening tests: are tests done in individuals with no
symptoms or sign of the illness.
➢ Diagnostic tests: are tests performed in persons with a
symptom or a sign of an illness.

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 Screening vs Diagnosis
 Screening  Diagnosis
➢ Non-Patients ➢ Patients
➢ Asymptomatic ➢ Symptomatic
➢ Test non-diagnostic ➢ Test diagnostic
➢ Low prevalence ➢ High prevalence

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 Diagnostic and screening tests

May be based on
– Standardized interviews,
– Physical examinations,
– Laboratory tests,
– More sophisticated measurements
 radiography,
 electro-cardiograph,
 slit-lamp examination.
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 Timeline of disease

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 Different types of screening
1. Mass screening:
 It involves the screening of the whole population.
2. Multiple or multi-phase screening:
 It involves the use of a variety of screening tests on
the same occasion.
3. Case finding or opportunistic screening;
 It is restricted to patients who consult a health
practitioner for some other purposes.

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 Considerations in Screening
 Severity
 Prevalence
 Understand Natural History
 Diagnosis and Treatment
 Cost
 Safety
 Efficacy

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 The Principles of Screening

 The choice of disease for which to

screen;
 The nature of the screening test or tests
to be used;
 The availability of a treatment for those
found to have the disease;
 The relative costs of the screening.

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 Criteria for a Successful Screening
Program
❑ Disease
 „Present in population screened
 Prevalence of the detectable pre-clinical phase must be high
 „High morbidity or mortality; must be an important public
health problem
 „Early detection and intervention must improve outcome.
 „Decrease in mortality and possibly incidence on the
population level.
 „The natural history of the disease should be understood,
such that the detectable sub-clinical disease stage is known
and identifiable
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  The disease must be an important health problem.

 There should be a recognizable latent or early symptomatic

stage.
 The natural history of the disease, including latent to
declared disease, should be adequately understood.

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 Diseases for which screening has
been recommended

 Cervical cancer

 Breast cancer
 Prostate cancer
 Colon cancer
 Diabetes
 Hypertension

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  There should be a suitable test or examination.

 The test should be acceptable to the population and providers.

 „Should be relatively sensitive and specific.
 „Should be simple and inexpensive.
 „Should be very safe.

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  There should be an acceptable treatment for the patients with
recognized disease.
 There should be facilities for diagnosis and treatment should be
available.
 There should be an agreed policy on whom to treat as patients.

 „It is unethical to offer screening when no services are available

for subsequent treatment

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 The cost of case finding (including diagnosis and treatment of
patients diagnosed) should be economically balanced in relation to
possible expenditure on medical care as a whole.
 Case finding should be a continuing process and not a "once for all"
project.

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 Validity of Screening Tests
Key Measures
 „Sensitivity
 „Specificity
 „Positive predictive value
 „Negative predictive value

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 Terminology
 Validity is analogous to accuracy.

 The validity of a screening test is how well the given

screening test reflects another test of known greater

accuracy.

 Validity assumes that there is a gold standard to which a

test can be compared.

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 Screening tests

1. Validity (accuracy) of test

– Sensitivity
– Specificity
2. Performance of screening test
– Predictive Value Positive (PV+)
– Predictive Value Negative (PV-)
3. Reliability
– Percentage of Correct Classification

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 Outcomes of a Screening Test
True Disease Status

Screening Positive Negative Total

Test

Positive True Positives False Positives TP+FP

(TP) (FP)

Negative False Negatives True Negatives FN+TN

(FN) (TN)

Total TP+FN FP+TN TP+FP+FN+TN

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 •The fraction of those with the disease
correctly identified as positive by the test.
Sensitivity •Proportion of individuals who have the
disease who test positive.
•Tells us how well a “+” test picks up
disease.
The fraction of those without the disease
correctly identified as negative by the test.
Proportion of individuals who do not have
Specificity
the disease who test negative.
„Tells us how well a “-” test detects no
disease.
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 Validity of Screening Tests
True Disease Status
+ -

+ a b

- c d

Sensitivity: The probability of testing

positive if the disease is truly present

Sensitivity = a / (a + c)
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 Validity of Screening Tests
True Disease Status
+ -

+ a b

- c d

Specificity: The probability of screening

negative if the disease is truly absent

Specificity = d / (b + d)
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 Screening Principles
Sensitivity
 „The ability of a test to correctly identify those who have a
disease.
➢ A test with high sensitivity will have few false negatives.
Specificity
 „The ability of a test to correctly identify those who do not
have the disease.
➢ A test that has high specificity will have few false positives.

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 Predictive values
❑Measures whether or not an individual actually has the
disease given the results or a screening test.
❑„Affected by:
➢„Specificity
➢„Prevalence of preclinical disease
➢„Sensitivity

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 •Positive predictive value (+PV):
 Is the probability of the presence of the disease among those
tested positive for the screening
 The fraction of people with positive tests who actually have
the condition.
(+PV = a/a+b)
 Negative predictive value (-PV):
 Is the probability of not having the disease when the
test result is negative (normal).
 The fraction of people with negative tests who
actually don't have the condition.
(-PV = d/c+d)

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 Combining Screening Tests

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 Risks of Screening
 True Positives
➢„
“labeling effect” (classified as diseased from the time of the test
forward).
 „False Positives
➢ „Anxiety
➢ „Fear of future tests
➢ „Monetary expense
 „False Negatives
➢ „Delayed intervention
➢ „Disregard of early signs or symptoms which may lead to delayed
diagnosis

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 Validity of Screening Tests
Breast Cancer
Physical Exam + -
and Mammo-
graphy + 132 983

- 45 63650

Sensitivity: a / (a + c)
Sensitivity =
Specificity: d / (b + d)
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Specificity = 11/9/2023
 Validity of Screening Tests
Breast Cancer
Physical Exam + -
and Mammo-
graphy + 132 983

- 45 63650

Sensitivity: a / (a + c)
Sensitivity = 132 / (132 + 45) = 74.6%

Specificity: d / (b + d)
Specificity = 63650 / (983 + 63650) = 98.5%
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 Validity of Screening Tests
Sensitivity: a / (a + c)
Sensitivity = 132 / (132 + 45) = 74.6%

Specificity: d / (b + d)
Specificity = 63650 / (983 + 63650) = 98.5%

Sensitivity: Screening by physical exam and

mammography will identify 75% of all true breast
cancer cases.

Specificity: Screening by physical exam and

mammography will correctly classify 98.5% of all
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free.
 CALCULATING THE RATES Examples

A test is used in 50 people with disease and 50 people

without. These are the results:

Disease
+ -
+ 48 3 51
Test 2 47 49
-
50 50 100
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 Disease
+ -
+ 48 3 51
Test 2 47 49
-
50 50 100

Sensitivity = 48/50 = 96%

Specificity = 47/50 = 94%
Positive predictive value = 48/51 = 94%
Negative predictive value = 47/49 = 96%
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 quiz
For the following screening test determine the:
1. Validity of the test (2pts)
2. Performance of the test (2pts)
3. today’s attendance (1pt)

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 Suitable Test
Breast Cancer Screening Program - Heath Insurance Plan
HIP) Women assigned to screening or usual care.
Screening consisted of yearly mammogram and physical
exam. Five years of follow-up produced these results:

Breast Cancer

Not Total
Confirmed Confirmed

Screening Positive 132 983 1,115

Test
Negative 45 63,650 63,695
Result
Total 177 64,633 64,810
creening 44 11/9/2023