Chapter 8

SCREENING
 Objectives

At the end of this chapter students able to:

• Define what a screening is
• Know the difference between diagnosing and
screening
• Understand the function of screening
• Know how the validity and reliability of screening
tests is established
• Know what sensitivity, specificity and predictive
values are
 Screening
Definition:
The presumptive identification of
unrecognized disease or defect by the
application of tests, examinations or
other procedures which can be applied
rapidly.
 Continued…
• Screening tests sort out apparently well
persons who probably have a disease from
those who probably do not.
• A screening test is not intended to be
diagnostic.
• The purpose of health interventions is to
reduce severe morbidity and mortality by
shifting the natural history of the disease to
the right and making disease less severe.
 Assumption of Screening Programs
Early detection will lead to more favorable prognosis

Natural History of Disease

Initiation Disease ComplicationsDeath

Clinical
detectable from the
Symptoms disease
by Screening
 Continued…

• One way of achieving in detection of

diseases at early stage of its natural course
is by applying a screening test.
 Aim of screening program

 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.
 To protect society from contagious disease
 Rational allocation of resources
 Selection of healthy individuals: employment,
military…
 Research; study on natural history of diseases
 Cont…
A suitable screening test or procedure should be
available and be:
1. Valid - Sensitive and specific
2. Reliable
3. Acceptable to the population screened
4. Reasonably inexpensive and safe
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.
 WHO Criteria for Screening:
Is it an important health problem?
Is there a treatment for patients?
Are there facilities in place for diagnosis and
treatment?
Is it detectable pre-clinically?
Is there a suitable screening test?
Is the screening test acceptable to people?
 Continued…
Is the natural history of disease
understood?
Are the costs acceptable?
Is it a continuous process
 When examining a screening test we
tend to look most closely at its

Validity: is the ability of the screening test to

successfully separate individuals who do and
do not have a preclinical disease.

Reproducibility (reliability): is the ability of a

screening test to give the same result on
repeated testing.
How do we judge the validity of a screening
test?
We compare the screening test against some “Gold
standard”
Disease “Gold standard”
Test Result Present Absent
Positive True positive (TP) False positive
(FP)
Negative False negative (FP) True negative
(TN)
As a measure of the validity of the test we calculate:

Sensitivity
= the probability that a test correctly classifies as positive
individuals who have the disease.
Or
Number of individuals with preclinical disease who test positive x 100

Number of individuals with preclinical disease

Or

How often does a test detect the disease if it is truly

present?
Specificity
= the probability that a test correctly classifies individuals
without preclinical disease as negative.
Or

# of individuals without preclinical disease who test negative x 100

Number of individuals without preclinical disease

Or

How often does a test give a negative result if the

disease is truly absent?
 Disease status “Gold standard”
Test Result Present Absent Total
Positive TP FP All who test +
Negative FN TN All who test -
Total All with disease All without disease Grand total

Sensitivity = TP x 100

TP + FN

Specificity = TN x 100
 Predictive value
• Is the main way to measure a screening
program’s feasibility.
• Depends on:
Sensitivity
Specificity
Prevalence of the underlying condition in
the population to whom the test is
applied.
 Continued…
• It has two components:
A. Positive predictive value a positive test
(PVPT): is the proportion of individuals
with a positive test who have preclinical
disease.

PVPT = TP x 100

TP + FP
 Continued…
B. Predictive value of a negative test (PVNT):
is the proportion of individuals without
preclinical disease who test negative.

PVNT = TN x 100

TN + FN
A hypothetical breast cancer
screening program in a ‘low
prevalence’ population
Breast cancer
Blood test
Yes No Total

Positive 190 796 986

Negative 10 39,004 39,014
Total 200 39,800 40,000
• Sensitivity = (a/a + c) x 100
= (190/190 + 10) x 100
= (190/200) x 100
= 95%
• Specificity= (d /b + d) x 100
= (39,004/ 796 + 39,004) x 100
= 39,004/ 39,800 x 100
= 98%
PVP= (a/(a + b)) x 100
= (190/(190 + 796)) x 100
= (190/ 986) x 100
=19.3%
PVN= (d/c + d) x 100
= (39,004/ (10 + 39,004)) x 100
= (39,004/39,014) x 100
= 99.97%
 A hypothetical breast cancer
screening program in a ‘high
prevalence’ population
Breast cancer
Blood test
Yes No Total

Positive 380 792 1,172

Negative 20 38,808 38,828

Total 400 39,600 40,000

• Sensitivity= 380/400 x 100
= 95%
• Specificity= 38,808/39,600 x 100
= 98%
• PVP= 380/1172 x 100
= 32.4%
• PVN= 38,808/39, 600 x 100
= 99.95%
  A high PVP is essential for a successful screening
program because the program detects a large proportion
of actual cases among individuals with positive results.
For example;

Prevalence PVPT PVNT

(per 1000)
1 4.1% 99.99%
2 8.0% 99.97%
5 17.9% 99.93%
10 30.5% 99.87%
50 69.6% 99.3%
100 82.9% 98.5%
THANK YOU!!