SCREENI

NG
Moderator: Presenter:
Dr JAHNAVI RAJAGOPAL Dr MONISHA K
ASSISTANT PROFESSOR POST GRADUATE

1
Table of Contents
• Introduction

• Definition

• Screening and Diagnostic tests

• Lead time

• Aims and Objectives

• Possible outcomes
2
• Uses of Screening

• Types of Screening

• Criteria for Disease to be Screened

• Criteria for Screening Test

• Evaluation of Screening Test

• Summary

• References
3
 Introduction
Iceberg phenomenon of Disease

DIAGNOSED

UNDIAGNOSED

4
 History of Screening Programs

• Periodic Health Examination

Consumes physician time
Expensive
Small population

5
Screening Vs Periodic
Health
Tests
Examination

Less physician time

Inexpensive

Larger population

6
 Definition

• The search for unrecognized disease or defect by means

of rapidly applied tests, examinations or other procedures

in apparently healthy individuals

7
Screening Tests vs
Tests
Testing for diseases in
Individuals who are not
seeking healthcare
Diagnostic
To confirm or refute the
existence of disease

Mammogram FNAC / biopsy

8
Screening Tests vs Diagnostic
Tests
• Done on apparently healthy • Done on those who are sick

• Applied to groups • Applied to single patients

• Test results are final • Diagnosis is not final
• Based on one criterion or cut- • Based on evaluation of a number
off point
of findings

9
Screening Tests vs Diagnostic
Tests
• Less expensive • More expensive

• Less accurate • More accurate

• Not a basis for treatment • Used as a basis for treatment

• The initiative comes from • The initiative comes from a

the investigator patient with a complaint

10
 Case finding
• Detecting diseases in individuals seeking healthcare
for other reasons

Case finding Diagnostic test

VDRL test for pregnant VDRL test for patients with
women genital lesions

11
 Disease
Process

Disease First Final Usual

onset Possible Critical time of
detection detection Diagnosis diagnosis
A

Screening time
B

Lead Time

12
 Aims and Objectives

• To alter the course of disease by early detection and

treatment

• To sort out from a large group of apparently healthy

persons those likely to have the disease

13
 Possible outcomes of Screening
Apparently healthy

(Screening Tests)

Apparently Normal Abnormal

Periodic re-screening Diagnostic test

Normal Intermediate Abnormal

Periodic Follow up Treatment

14
re-screening
 Uses of Screening

Case Detection

• Presumptive identification

• Screen for their own benefit

• Initiated by medical and public health personnel

• Prescriptive screening

15
Control of Disease

• For the benefit of others

• Reduce burden of disease

• Permit more effective treatment

• Prospective screening

16
Research Purposes

• Basic knowledge about the natural history of diseases

• Prevalence and Incidence

Educational Opportunities

• Creating public awareness

• Educating Health Professionals

17
 Types of Screening

• Mass Screening

• High-risk or selective screening

• Multiphasic screening

18
Mass Screening

• Whole population or a sub-group

• Irrespective of particular risk individual

19
High-risk Screening

• Selective Screening

• High-risk groups

• On the basis of Epidemiological research

• Early preventive measures

• Economical use of resources

20
 Multiphasic screening

• Two or more screening tests at one time

• Increases the cost of health services

• No benefit on population in term of mortality and morbidity

reduction

21
 Criteria for Disease to be Screened

Diabetes , CVD, Chicken pox

Carcinoma, TB

Significant time lag Onset of disease is known

between disease onset only after the appearance
unusual time of diagnosis of signs and symptoms

22
• Important Public Health

• Recognizable latent or early asymptomatic stage

• Natural history of the condition should be known

• Test that can detect the disease early

23
• Facility to confirm the diagnosis

• Effective treatment

• Cut-off value

• Early detection – reduction in morbidity and mortality

• Expected benefits be higher than the cost and risk

24
 Cervical cancer
Pap smear

_ +

Retest Punch biopsy

_ +

Retest Laser ablation

Conization
TAH
25
Criteria for screening test

• Acceptability

• Repeatability

• Validity

26
Repeatability

• Reproducibility

• Affected by:
• Observer variation
• Biological Variation
• Errors relating to technical methods

27
Observer Variation
• Intra-observer variation

• Single Observer on same subject or material

• Within-Observer
• Minimized by taking several replicate measurements

28
• Inter-Observer Variation
• Variation between different observer on same subject
• Between Observers
• Can never be eliminated absolutely
• Tested by Repeat measurements same time

29
 Biological Variation

• Fluctuation in the variate measured in same individual

 Changes in the parameters observed

30
 Variations in the way patients perceive their symptoms

If YES we can send him to If YES they will send me to

deaddiction centre, so its
deaddiction centre
NO

31
 Regression to mean

32
Errors relating to technical methods

• Variations due to inherent methods

e.g., defective instruments, erroneous calibration, faulty

reagents

33
Validity
Ability of the test to separate/distinguish those who have
the disease from those who do not

• Components

• Sensitivity
• Specificity

34
 To Calculate the sensitivity and specificity of a test

who “really” has the disease who “does not”

35
 Sensitivity Specificity

×100 ×100

36
 Issues of False Positive and False Negative

• False Positive:

• Burden on Health care system

• Anxiety and worry

• Brought back to more sophisticated and more expensive tests

• False Negative:

• False reassurance

• If the disease is critical – More detrimental

37
Calculation of the Sensitivity and Specificity

38
 Yield
Disease that is diagnosed as a result of screening effort

• Depends on many factors

• Sensitivity of test

• Specificity of test

• Prevalence of the disease

• Participation of individuals in detection programmes

39
Predictive accuracy

Predictive value of a positive test Predictive value of a negative test

• Positive - Disease • Negative - Does not have the

• PPV disease

• Prevalence - PPV • NPV

40
Relationship of Disease Prevalence to PPV

41
Relationship of Specificity to PPV

42
 Evaluation of Screening Test

Sensitivity
Specificity
Predictive value of a positive test
Predictive value of a negative test
Percentage of false negatives

• Percentage of false positives

43
Number of people Tests of Continuous variables

4
5
4
0 TN FP FN TP
3
5
3
0
2 FP FN
5
2 40 80 120 160 200 240 280 320
0
1 RBS (mg/dL)
5 Sensitive
1
Specific
0
5 44
• Disease prevalence :
If Prevalence is high
Cut off point is set at a lower level
Which will increase the sensitivity
• Disease :
 If the disease is lethal – Cancer
Sensitivity should be increased

 If the disease is more prevalent – Diabetes mellitus

Specificity must be high

45
Validity and
Reliability

Valid , not reliable

46
 Use of Multiple Tests

• More than one screening tests applied on same individuals

• Of two approaches:
• Sequential (Two-stage) testing
• Simultaneous Testing

47
 Sequential Testing:
• Two-stage testing

Less expensive, less invasive or less comfortable test

Test with greater sensitivity and specificity

48
Two-stage screening program

49
Two-stage screening program

Net sensitivity
315
= 63%
350

Net specificity
7600 +1710
= 98%
9500

50
 Simultaneous testing:

• To be positive - positive by either of two test or by both tests

• To be negative- negative by both tests

51
 Net sensitivity using two simultaneous tests

16 160 180 36 1000

144

200

Test A sensitivity 80%

Test B sensitivity 90%

16 + 144 + 36
200

196 = 98%
200 52
 Net Specificity of simultaneous testing

48 480 720 288 1000

432

800

Test A specificity 60%

Test B specificity 90%
432
= 54%
200

53
Evaluation of Screening Programmes

• Randomised controlled trial

• Uncontrolled trials

• Other methods

• Case control studies

• Comparison studies

54
 Summary
• Screening is a means of detecting unrecognized disease in apparently
healthy individual and not seeking health care

• Screening programs should concentrate on conditions where the

time lag between the disease's onset and its final critical point is
sufficiently long

• Construction of accurate tests that are both sensitive and specific is a

key obstacle to the wide application of screening

55
References

• Park K. Park’s textbook of preventive and social

medicine.26th ed. Jabalpur: Bhanot; 2021.

• Celentano DD, Szklo M. Gordis Epidemiology. 6th

ed. Philadelphia, PA: Elsevier - Health Sciences Division;
2019.

56
Thank you
57