SCREENING FOR DISEASE

Screening;
 It is defined as, ‘ the search for unrecognized disease or defect by
means of rapidly applied tests, examinations or other procedures in
apparently healthy individual’.
 Detection of hidden disease .
 Different from Periodical health examination in ,
o Capable of wide application
o Relatively inexpensive
o Requires less physician time
 Difference btw Screening test and Diagnostic tests .
S.NO SCREENING DIAGNOSTIC
TEST TESTS
1. Done on healthy Done on sick
individuals individuals
2. Applied to groups Applied to single
patients
3. Test results are Diagnosis is not final
arbitrary and final but modified in light of
new evidence,
diagnosis is the sum
of all evidence.
4. Based on one criterion Based on evaluation
or cut-off point of a number of
symptoms, signs and
laboratory findings.
5. Less accurate More accurate
6. Less expensive More expensive
7. Not a basis for Used as a basis for
treatment treatment
8. The initiative comes The initiative comes
from the investigator or from a patient with a
agency providing care. complaint.
Lead time;

 See diagram in pg.149 in Park.

 There will be a time lag btw detection of disease and onset of disease.
 This period contains critical points that determines the severity of the
disease and the success of treatment.
 Lead time is defined as the advantage gained by screening i.e., the
period between diagnosis by early detection and diagnosis by other
means.
 Let us consider A as the usual outcome of the disease and B is the
outcome if the disease is detected early and therefore B-A is the
advantage or benefit gained by early detection of the disease.

Aims and Objectives of screening;

 The basic purpose of screening is to sort out from a large group of apparently
healthy persons those likely to have the disease or at increased risk of the
disease under study, to bring those who are "apparently abnormal" under
medical supervision and treatment
 Screening is carried out in the hope that earlier diagnosis and subsequent
treatment favourably a lters the natural history of the disease in a significant
proportion of those who are identified as "positive".
Uses of screening;
 Case detection
- Prescriptive Screening.
- Presumptive identification of unrecognized disease which does not
arise from patients request like in neonatal screening.
- Screened primarily for the patients benefit.
- Some diseases sought are PKU, Pulmonary TB, Diabetes mellitus etc..
 Control of disease
- Prospective screening.
- People are examined for the benefit for the others.
- E.g. Screening of immigrants for TB, Streptococcal infections(to
prevent rheumatic fever ).
- Helps in preventing the spread of disease and their mortality.
 Research purposes
- Screening aids in obtaining basic knowledge about diseases whose
natural history is not fully known.
- E.g. Cancer and hypertension
 Educational purposes
- Providing public awareness and educating health professionals.
Types of screening;
1. Mass Screening
2. High risk screening or selective screening
3. Multiphasic Screening
A. MASS SCREENING:
- Screening of a whole population or a sub-group (for
example all adults)
- Received enthusiastic support in the past
- Not a useful preventive measure unless backed up by
suitable treatment that will reduce the duration of illness
or alter its outcome.
- E.g. TB screening
B. HIGH RISK SCREENING:
- Applied selectively to high risk groups defined on the basis
of epidemiological research.
- For example, (i) Screening Cervical Cancer in lower social
group, (ii) Screening the family members for additional
cases.
 - Risk factors are apparently antedate the development of
actual disease like elevated serum cholesterol level is
associated with devolpment of CHD
- Preventive measures can be applied before the disease
occurs and there will economical use of resources.
C. MULTIPHASIC SCREENING:
- Defined as application of two or more screening test in
combination to a large no. of people at one time to carry out
separate screening test for a single disease.
- This include Health questionnaire, clinical examination, blood
investigations, urine examinations, audiometry etc.. – all of which
is performed rapidly with appropriate staff organization and
equipments.
- This screening has not shown any benefits in reduction of
mortality and mobidity rates inspite of high cost of health
services.
CRITERIA FOR SCREENING
Based on two considerations – (i) Disease, (ii) tests
A) DISEASE :
- Condition should be an important health problem.
- Should be recognizable latent or at early
recognizable stage.
- Natural history of the disease should be adequately
understood.
 - There should be a test that can detect the disease
prior to onset of signs and symptoms.
- Facilities should be available for confirmation of
diagnosis.
- There should be an effective treatment.
- Agreed on policy concerning whom to treat as
patients(eg. Lower ranges of blood pressure)
- Good evidence that early detection and treatment will
reduce the mortality and morbidity rates.
- Expected benefits of earlt detection exceed the risks
and costs
B) SCREENING TESTS :
1) ACCEPTABILITY:
- Test should be acceptable to the people at whom it is aimed
- In general the tests are painful, discomforting or embarrassing are
not likely to be acceptable in mass campaigns
2) REPEATABILITY:
- The test must give consistent results when repeated more than
once on the same individual or material under same conditions
- Depends on three factors
I) Observer variation
*Intra observer Variation – Variation between
repeated observation by the same observer on the same
subject or material at the same time – Minimized by taking
average.
*Inter observer Variation – Variation between
different observer on the same subject or material –
(i)Standardization of procedures (ii) Intensive training of
all observers (iii)Making use of two or more observers for
independent assessment .
 II) Biological variation
*This variation may occur due to physiological
variables.
*FLUCTUATION in variate measured in individual
may be due to
(a) Changes in parameter observed – like in
cervical smear taken from a woman may vary form
day to day,
(b) Variation in the way the perceive their
symptoms and answer – Common Subject Variation –
error of the patients in recollection of past symptoms
or in the questionnaire asked to the patients .
(c) Regression to the mean – There is a
tendency
III) Errors related to technical methods
*This includes defect in instruments, erroneous
calibration, faulty reagent or inappropriate tests.
3) VALIDITY:
- Refers to what extend the test accurately measures
which it purports to measure.
- Has two components Sensitivity and Specificity
 VALIDITY
SCREENING TEST DIAGNOSIS TOTAL
RESULTS DISEASED NOT
DISEASED
POSITIVE a ~ true b ~ false a+b
positive positive
NEGATIVE c ~ false d ~ true c+d
negative negative
TOTAL a+c b+d a+b+c+d
Evaluation of a screening test
The following measures are used to evaluate a screening
test:
(a) Sensitivity = a/ (a + c) x 100
(b) Specificity = d/(b + d) x 100
(c) Predictive value of a positive test = a/(a + b) x 100
(d) Predictive value of a negative test = d/(c + d) x 100
(e) Percentage of false-negatives = c/ (a + c) x 100
(f) Percentage of false-positive = b/(b + d) x 100
Sensitivity - defined as the ability of a test to identify correctly
all those who have the disease, that is "true-positive"
Specificity - defined as the ability of a test to identify correctly
all those who do not have the disease, that is "true-negatives"
False-negatives - patients who actually have the disease are
told that they do not have the disease.
. False-Positives - patients who do not have the disease are

told that they have the disease.

Some of the other criteria for screening tests are Yield,
simplicity, safety , rapidity, ease of administration and cost.