Screening in disease control

Misrak G. (BSc., MSc., MPH)

2022

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Learning objectives

By the end of this session, you should be able to:

♦ Define and explain epidemiologic screening
principles
♦ Identify criteria to be fulfilled before a screening
program is introduced
♦ Understand & calculate sensitivity, specificity,
PPV and NPV of a screening test

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What is screening?
♦ Application of a test or procedure to asymptomatic,
apparently well individuals, in order to separate those
with a relatively high probability of having a given disease
from those with a relatively low probability of having the
disease

♦ ‘The examination of asymptomatic people in order to

classify them as likely or unlikely to have the disease of
interest.’

♦ Early detection of disease in the hope of modifying

prognosis
 b/c those who have a positive result from the
screening test are made to go further evaluation

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Cont…

Common screening test

♦ Pap smear for cervical cancer
♦ Fasting blood cholesterol for heart disease
♦ Fasting blood sugar for diabetes
♦ Blood pressure for hypertension
♦ Mammography for breast cancer
♦ Ocular pressure for glaucoma

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Main Aim of Screening

♦ To reverse, halt, or slow the progression of

disease more effectively than would probably
normally happen

♦ To alter the natural course of disease for a

better outcome for individuals affected

♦ Reduce morbidity and mortality through early

detection and treatment

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Aim of screening…

♦ Protect society from contagious disease

♦ Rational allocation of resources
♦ Selection of healthy individuals: employment,
military…
♦ Research: study on natural history of disease…

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What characteristics of a disease make it
appropriate for screening?
1. Important public health problem – frequent or
serious
2. Reasonably long, recognizable pre
symptomatic stage
3. Effective treatment exists and is available, or
effective ways of preventing spread
4. Treatment (or measures take to prevent
spread) should be more effective if initiated in
the pre-symptomatic stage than when
initiated in symptomatic patients

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Cont…

A suitable screening test or procedure should be

available and be:
1. Reliable
2. Sensitive and specific
3. Acceptable to the population screened
4. Reasonably inexpensive and safe

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WHO Criteria for Screening

♦ The condition being screened for should be an

important health problem
♦ The natural history of the condition should be
well understood
♦ There should be a recognizable latent or early
stage
♦ There should be a suitable method for detection
♦ The screening method should be acceptable to
the population

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WHO Criteria…

♦ There should be an accepted treatment for

those with the condition
♦ There should be an agreed policy on who to
treat
♦ Facilities for diagnosis and treatment should be
available
♦ The costs of detection should be balanced in
relation to overall healthcare spending
♦ Screening should be ongoing and not one-off

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Types

Mass vs. selective screening

♦ Mass screening involves the screening of the
whole Population
Case finding or Opportunistic screening
♦ It is restricted to patients who consult a health
practitioner for some other purposes
Multiple or multi-phase screening
♦ It involves the use of a variety of screening tests
on the same occasion
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“Gold standard”

♦ Confirmatory test

♦ Is the best available information, which is the

basis for evaluation of the performance of a
screening (second diagnostic) test which is
usually is cheaper, easier, or safer.

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Question

♦ How do we judge the validity of a screening

test?
We compare the screening test against some
“gold standard”

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Validity of a Screening Test

♦ Validity of a test is the ability to differentiate

accurately between those who have the disease
and those who do not

♦ Sensitivity and Specificity are two measures of

the validity of a screening test

♦ Sensitivity and specificity can also be taken as

measures of validity for other tests which are
applied for diagnostic purposes
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Validity of a Screening Test

♦ Sensitivity is the ability of a test to correctly

identify those who have the disease
♦ is the probability of a positive test in people with
the disease
♦ Specificity is the ability of a test to correctly
identify those who do not have the disease.
♦ the probability of a negative test in people
without the disease

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Two-by-Two table for Screening Evaluation

DISEASE STATUS
(Gold standard)
Test result POSITIVE NEGATIVE
POSITIVE True positive False positives
(a) (b)

NEGATIVE False negatives True negatives

(c) (d)

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Sensitivity
• Ability of a test to correctly identify those with the
disease
Confirmatory test
Gold standard
Positive Negative
Screening

Positive
TP FP TP + FP
Negative FN TN FN + TN
TP+ FP + TN
FN

• Probability of a positive test in people with the

disease
TP
Sensitivity = 17
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Specificity
• Ability of a test to correctly identify those without
the disease
Confirmatory test
Gold standard
Screening

Positive Negative
Positive TP FP TP + FP
Negative FN TN FN + TN
TP + FN FP + TN
• Probability of a negative test in people without
the disease
TN
Specificity =
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Example: Sensitivity and Specificity of breast cancer
screening examination
Breast cancer
Cancer Cancer not
Total
Confirmed confirmed

Screening test
(Physical Examination & mammography)
Positive 132 983 1115
Negative 45 63,650 63,695
Total 177 64,633 64,810

Sensitivity =132/177 = 74.6%

Specificity = 63,650/64,633 = 98.5%

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Validity of a Screening Test

• Sensitivity 74.6% means that of those diagnosed

with breast cancer during the study period,
approximately 75 % tested positive on the
screening procedure

• Specificity 98.5 % indicates that almost all

women who did not have the disease tested
negative

•It would be desirable to have a screening test that

was both highly sensitive and highly specific

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Example – Prostate cancer

♦ Suppose that 100,000 men were screened for

prostate cancer for the first time. Of these, 4000
men had a positive result on the screening blood
test; of those who tested positive, 800 had a
biopsy indicating a diagnosis of prostate cancer.
Among the remaining 96,000 men who screened
negative, 100 developed prostate cancer within
the following year and were assumed to be false
negatives to the screen.

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Questions

A. Set up the two-by-two table for these

data.
B. What is the prevalence of prostate cancer
in this population?
C. Calculate and interpret the sensitivity of
this screening test.
D. Calculate and interpret the specificity of
this screening test.

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 Solution

♦ Prevalence = 900/100,000
= 0.9%
Test Prostate Cancer Total
result ♦ Sensitivity = 800/900 =
Present Absent 88.8 % it means that 88.8
Positive 800 3200 4000 % of men who have
Negativ 100 95,900 96,000 prostate Ca tested positive
e on the screening test.
Total 900 99,100 100,000 ♦ Specificity =
95,900/99,100 = 96.8% It
means that 96.8% of the
men who did not have
prostate Ca tested negative
on the screening Test.

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Specificity and sensitivity

♦ Increased sensitivity decreases the specificity

– Leads to false positives
– people wrongly diagnosed as having the
disease
– unnecessary panic among people & Health
workers
– Unnecessary exposure for treatment
– Unnecessary wastage of resource (human, time,
drug, etc)
– Unnecessary stress on the health system
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Wrong negative implication external relation
Specificity and sensitivity

♦ Increased specificity decreases the sensitivity

– Leads to false negatives
– people wrongly diagnosed as not having the
disease
– delay in diagnosis
– Negative implication on prognosis of disease
– Unnecessary wastage of resource (human,
time, drug, etc) for sever disease
– Unnecessary stress on the health system

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Cont…..

♦ Sensitivity should be increased at the expense of

specificity when:
– Consequence of missing a case is a problem
– Disease is serious and definitive treatment
exists
– Disease easily spreads (eg. syphilis, HIV)
– Subsequent diagnosis and treatment have
minimal costs and risk (eg further series of
blood pressure reading for HTN)
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♦ Specificity should be increased over sensitivity
when
– having the disease results in stigmatization/
discrimination
– costs or risks associated with further diagnostic
techniques are substantial

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 Testing in parallel and testing in series
♦ One way of addressing the problem of the trade-
off between sensitivity and specificity is to use
the results of several screening tests together
♦ these tests can be administered either in parallel
or in series
♦ When screening tests are given in parallel, all
are administered at the same time, and persons
with positive results on any test are considered
positive
♦ parallel testing results in increased sensitivity
compared with that of each individual test
♦ it lower specificity because false positive
diagnoses
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are also more likely 28
 Testing in parallel and testing in series

♦ When screening tests are given in series, an

initial screening test is administered, and only
persons with positive test are evaluated with an
additional screening procedure
♦ testing in series results in an increase in
specificity compared with a single test

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Predictive Value of a screening

♦ How well does our screening test predict

who is diseased and who is not?

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Predictive Value

♦ Among those who screen positive, what

proportion actually has the disease?
Positive Predictive Value (PPV)

♦ Among those who screen negative, what

proportion actually do not have the
disease? Negative Predictive Value (NPV)

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 True Disease Status
Cases Non-cases
True False
Positive positive positive a+b
Screening
a b
Test c d
Results False True
Negative c+d
negative negative

a+c b+d
True positives a
PPV = =
All positives a+b
True negatives d
NPV = =
All negatives c+d

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 Example

Comparison of routine Reference test:

diagnosis of malaria and 100 fields read by 2
double read research slide technicians

Positive Negative

Screening test: Positive 1555 988

routine smear
at 10 hospitals
Negative 514 1394

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Example - Results

Sensitivity = 1555/2069= 75.2%

Specificity = 1394/2382= 58.5%

PPV= 1555/2543= 61.1%

NPP =73.1%

Prev = 46.5%

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Example

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Cont…

♦ PPV= 800/(4000)= 0.2= 20%

i.e: one fifth of the men who screen positive on test
have prostate cancer, leaving about 80% of men
screening positive falsely
 NPV = 95,900/96,000
• =0.998 = 99.9%
i.e. the test has perfect negative predictive
value.
Among those who are negative on the screening
test, we can be perfectly confident that none of
those individuals actually have the disease. 36
Reliability (Precision)
♦ Reliability refers to the consistency of results
when repeat examinations are performed on the
same persons under the same condition.
♦ There are 4 sources of variability that can affect
the reproducibility of results of screening test:
1. Biological variation
♦ inherent in the actual manifestation being
measured such as BP
♦ which varies considerably for a given individual
with time and other circumstances

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Reliability (Precision)

2. Variation due to the test method or

measurement which relates to the reliability of
the instrument itself, such as standard mercury
sphygmomanometer for BP
3. Intra-observer variability which refers to
differences in repeated measurements by the
same screener
4. Inter-observer variation which refers to
inconsistencies attributable to differences in the
way different screeners apply or interpret test
results. 38
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These variations can usually be reduced by:

1. careful standardization of procedures

2. an intensive training period for all observers
(or interviewers)
3. periodic checks on their work
4. the use of two or more observers making
independent observations.

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Potential Source of Bias in Screening

♦ Volunteer (Referral) bias: patient self selection

bias
– i.e. cases with better prognosis more likely to
attend
♦ Length time bias (chronicity & progression):
screening picks up more slow-growing lesions
than rapidly progressing or fatal conditions
♦ Lead-time bias (early diagnosis): prolongation of
apparent survival by earlier detection than late
comers
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 Thank you!!

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