SCREENING

OF DISEASE
Dr. Bhuwan Sharma
Associate Professor
Department of Community Medicine
PIMS, Jalandhar
TIP OF THE ICEBERG
PHENOMENON
WHAT IS SCREENING?
 Screening, in medicine, is a strategy used in a population to
identify the possible presence of an as-yet-undiagnosed
disease in individuals without signs of symptoms.
 This can include individuals with pre-symptomatic or
unrecognized symptomatic disease. As such, screening tests are
somewhat unusual in that they are performed on persons
apparently in good health.
COMMON EXAMPLES
 Cancer Screening
 PAP smear to detect potentially precancerous lesions and prevent
cervical cancer
 Mammography to detect breast cancer
 Colonoscopy and fecal occult blood test to detect colorectal cancer
 PSA to detect prostate cancer

 Sputum test to screen for exposure to tuberculosis

 Alpha-fetoprotein, blood tests and ultrasound scans for pregnant
women to detect fetal abnormalities
 Ophthalmoscopy and image grading for diabetic retinopathy
 SCREENING VS
DIAGNOSIS
Screening test Diagnostic test
 Done on apparently healthy  Done on those with indication or
sick
 Applied to groups
 Applied to single patient, all
 Test results are arbitrary and diseases are considered
final
 Diagnosis is not final but
 Based on one criterion or cut modified in light of new
off point evidence
 Less accurate  Based on evaluation of a number
of symptoms signs and findings
 Less Expensive
 More accurate
 Not a basis for treatment
 More expensive
 Used as basis for treatment
 CONCEPT OF LEAD
TIME

Lag time: Time between disease onset and diagnosis

Lead time: It is the advantage gained by screening i.e. the period between
early detection and diagnosis by other means
USES OF SCREENING
 Case Detection: The presumptive identification of unrecognized
disease which doesn’t not arise from the patient's request but is done
for the patient's own benefit eg. Neonatal screening
 Control of disease: This application of screening is to protect others
by diagnosing early the presence of a contagious disease
 Research purposes: Screening aids in obtaining more basic
knowledge about the natural history of chronic diseases
 Educational opportunities: Provide opportunities for creating public
awareness and for educating health professionals
TYPES OF SCREENING
 Mass screening : Mass screening means, the screening of a whole
population or a subgroup. It is offered to all, irrespective of the risk
status of the individual.
 High risk or selective screening : High risk screening is conducted
amongst populations at risk only. We may also screen for presence of
risk factors
 Multiphasic screening : It is the application of two or more screening
tests to a large population at one time instead of carrying out separate
screening tests for single diseases. However no benefit has been
observed in morbidity and mortality
 When done thoughtfully and based on research, identification of risk
factors can be a strategy for medical screening.
MASS SCREENING
 Application of screening test to large, unselected population. Everyone in the group is
screened regardless of the probability of having the disease or condition.
 Example:
 Screening for visual defects in school children
 Newborn screening program in Japan
 Mammography screen in women aged 40 or less

 Note: When mass screening was subject to critical review there appeared little to no
advantage for use in many instances
 Indiscriminate screening therefore is not a useful and preventive measure unless it is
backed up by suitable treatment that will reduce the duration of illness or alter its final
outcome
HIGH RISK
SCREENING
 Screening of selected high risk groups in the population.
 Example:
 Screening of HIV in high risk groups
 Screening of Down’s syndrome in a baby with familial history of Down’s
syndrome
 Screening for CA Cervix in low SES women

 These days screening is done for presence of risk factors as they

apparently antedate the development of actual disease. For eg.
 High serum cholestrol is a precursor of coronary heart disease

 High risk screening is also economically viable.

MULTIPHASIC
SCREENING
 The screening in which there is application of 2 or more screening
tests that are done during the same program.
 Although they have popular public opinion, they have increased cost
of the provrams. Their actual effect has not yet been studied.
 Eg. Multiple screening tests done on pregnant women
PRINCIPLES OF
SCREENING
 The disease should be an important health problem.
 There should be a treatment for the condition.
 Facilities for diagnosis and treatment should be available.
 There should be a latent stage of the disease.
 There should be a test or examination for the condition.
 The test should be acceptable to the population.
 The natural history of the disease should be adequately understood.
 There should be an agreed policy on whom to treat.
 The total cost of finding a case should be economically balanced in
relation to medical expenditure as a whole.
 Case-finding should be a continuous process, not just a "once and for
all" project.
LIMITATIONS
 Screening can involve cost and use of medical resources on a majority
of people who do not need treatment.
 Adverse effects of screening procedure (e.g. stress and anxiety,
discomfort, radiation exposure, chemical exposure).
 Stress and anxiety caused by prolonging knowledge of an illness
without any improvement in outcome. This problem is referred to
as overdiagnosis.
 Stress and anxiety caused by a false positive screening result.
 Unnecessary investigation and treatment of false positive results
(namely misdiagnosis with Type I error).
 A false sense of security caused by false negatives, which may delay
final diagnosis (namely misdiagnosis with Type II error).
A screening test has 3 major criteria to be
satisfied:
1.Acceptability

2.Repeatability

3.Validity
 ACCEPTABILITY
 Since a high rate of cooperation is necessary, it is important that the
test should be acceptable to the people at whom it is aimed.
 In general the tests that are painful, discomforting or embarrassing are
not likely to be accepted by the population.
 Eg
 colonoscopy for cancer of colon
 Night blood smear for testing of microfilariae
 REPEATABILITY
 Repeatability is the attribute of an ideal screening test.
 The test must give consistent results on the same individual under the
same conditions.
 The repeatability of the test depends on three factors:
 Observer variation:
These are differences in observations made by same observers or
different observers.
 Biological variation:
Physiological variables such as BP, blood sugar, serum
cholesterol etc. vary from person to person and time to time
The subject may experience symptoms differently as well
 Errors due to technical methods:
OBSERVER VARIATION
 Intra-observer variation:
“If a single observer takes two measurements (eg. Blood pressure) in the
same subject at the same time and each time obtained a different result.”
This variation can be avoided by taking the average of several replicate
measurements at the same time
 Inter observer variation
“This variation between different observers on the same subject or material,
also known as between-observer variation”
eg. One observer finds malaria parasite in a blood smear while the other
observer is unable to
 These variations can be decreased by –
1. Standardization of procedures
2. Intensive training of observers
3. Making use of two or more observers for independent assessment
BIOLOGICAL
VARIATION
 There is a biological variability associated with many physiological variables
such as blood pressure, blood sugar etc.
 These fluctuations are due to
 Changes in the parameters observed:
Cervical smears obtained from women may be normal one day and abnormal
the next day
 Variations in the way patients perceive their symptoms and answer:
This is a common subject variation. There may be errors in recollecting past
events in a questionnaire.
When the subject is aware he/she may not give correct information
 Regression to the mean:
There is tendency for values at the extremes of a distribution i.e. very high or
very low regress to the mean or average on repeat measurements. Eg. Blood
pressure in hypertension.
This is very important to evaluating the effects of a specific drug to reduce
blood pressure.
TECHNICAL ERRORS
 Repeatability may be effected by variations in the method. Eg:
 Defective instruments
 Erroneous calibration
 Faulty reagents
 Unreliable tests

Where these errors are large repeatability will be reduced and a single
test result may be unreliable.
 VALIDITY
 Validity or accuracy refers to the ability of the test to distinguish those
who have the disease from those who don’t

 Validity has 2 components:

 Sensitivity
 Specificity

 Both are expressed in percentages and together with predictive

accuracy form the inherent properties of a screening test
 SENSITIVITY
 The term sensitivity was introduced by Yerushalmy in 1940s as a
statistical index of diagnostic accuracy. It has been defined as “the
ability of a test to correctly all those who have the disease, that is
true positive.”
 A 90% sensitivity means 90% of the diseased population will be
detected by the test, true positive and the remaining 10% will become
the false negative.
WHEN TO USE A
HIGHLY SENSITIVE
TEST?
 A highly sensitive test is of clinical value when the result is negative
and the test helps ruling out disease.
 This test will have very few false negatives i.e. very few people with
the disease will actually be left out
 For example if a person comes up as negative when testing for HIV
via ELISA, we can be pretty sure he or she doesn’t have HIV.
 SPECIFICITY
 It is defined as “the ability of a test to identify correctly those
who do not have the disease, that is, true negative.”
 A 90% specificity means the test will detect 90% of the
diseased population as “true negative” while the other 10%
population will be detected as “false positive”
WHEN TO USE A
HIGHLY SPECIFIC
TEST?
 A highly specific test will have a large number of true negatives and
minimal false positives.
 i.e. someone who comes up as positive most likely has the disease.
 A negative test however isn't of much value because of the large
number of false negatives
PREDICTIVE
ACCURACY
 The predictive value of a test reflects its diagnostic power
 It depends upon sensitivity and disease prevalence.
 The predictive value of a positive test indicates the probability that a
patient with a positive test result has, in fact the disease in question
 More prevalent the disease, more accurate is the predictive value of a
positive screening test
 The predictive value of a positive result falls as disease prevalence
declines
NO SCREENING TEST
IS 100% SENSITIVE
AND SPECIFIC
FALSE NEGATIVES
The term means that patients who actually have the disease are told that
they do not have the disease .
Such a patient may ignore the development of signs and symptoms
which can postpone treatment
This could be detrimental when the disease in question is a serious one
and another screen will not be repeated any time soon
A screening test which is very sensitive has few false negatives

Lower the sensitivity larger the false negatives

FALSE POSITIVE
 The term means that patients who do not have the disease are told that
they have it.
 In this case a normal, healthy person may be subjected to further
diagnostic tests, at some inconvenience, discomfort, anxiety and
expense until their freedom of disease is established
 High specificity will lead to fewer false positives
 False positives cause undue burden on diagnostic facilities and
discredit the screening programmes
• ‘a’ - the individuals the number of individuals found positive on the test who have the
disease that’s being studied
• ‘b’ - those who have a positive test result but do not have the disease
• ‘c’ - those who have a negative test result but have the disease
• ‘d’ - those who have a negative test result and don’t have the disease
 EVALUATING A
SCREENING TEST
 Sensitivity = a/(a+c)*100
 Specificity = d/(b+d)*100
 Predictive value if a positive test = a/(a+b)*100
 Predictive value if a negative test = d/(c+d)*100
 Percentage of false positive = c/(a+c)*100
 Percentage of false negative = b/(b+d)*100

• ‘a’ - the individuals the number of individuals found positive on the test who have the
disease that’s being studied
• ‘b’ - those who have a positive test result but do not have the disease
• ‘c’ - those who have a negative test result but have the disease
• ‘d’ - those who have a negative test result and don’t have the disease
 YIELD
 Amount of previously unrecognized disease that is diagnosed as a
result of the screening effort. It depends upon many factors:

 Sensitivity and specificity

 Participation of the individuals involved
THANK
YOU!