SCREENING

Dr. Arup Chakraborty

Associate Professor
Department of Community Medicine
Medical College, Kolkata
INTRODUCTION
 Biggest Challenge in Preventive Medicine is
to distinguish between people who have the
disease and those who do not..
ICEBERG PHENOMENON
 Gives an idea of
progress of a
disease from its
subclinical stages
to overt disease
 HIDDEN:
Subclinical cases,
carriers,
undiagnosed cases.
SCREENING AS PREVENTIVE
TOOL
 Definition: The  Today, Screening is
Search for considered a form of
unrecognized secondary prevention.
disease or defect by  It detects disease in
means of rapidly its early asymptomatic
phase whereby early
applied tests,
treatment can be
examinations or the given hence disease
other procedures in can be cured or its
apparently healthy progression can be
individuals. delayed.
LEAD TIME
 The advantage gained by screening. (The
period between diagnosis by early detection
and diagnosis by other means.)

 Screening programmes work better where

the time lag between the disease’s onset and
its final critical point are sufficiently long.
CONCEPT OF LEAD TIME
SCREENING VS DIAGNOSTIC
TESTS
1. Done on apparently 1. Done on sick or ill individuals
healthy individuals 2. Applied on single patient
2. Applied to groups 3. Diagnosis is not final
3. Results are arbitrary and 4. Based on evaluation of a no.
final of signs/symptoms & lab
findings
4. Based on one criteria and
cut-off 5. More accurate
5. Less accurate 6. More expensive
7. Used as a basis for treatment
6. Less expensive
8. Initiative comes from a
7. Not a basis for treatment
patient
8. Initiative comes from
investigator

Screening Diagnostic tests

USES OF SCREENING
1. CASE DETECTION: “Prescriptive
screening”
Defined as “The presumptive identification of
unrecognized disease, which does not arise
from a patients request”.
Example: Neonatal screening through ‘Heel
Prick Blood Sample’.
Here people are screened primarily for their
own benefit.
USES OF SCREENING
2. CONTROL OF DISEASE: “Prospective
screening”
Screening of Immigrants from infectious diseases
like Corona, Ebola, TB, Syphilis to protect the
home population.Screening for HIV, STD’s etc.
Here ppeople are examined for the benefit of
others.
Screening programme may, by leading to early
diagnosis permit more effective treatment and
reduce the spread of infectious disease and
mortality.
USES OF SCREENING
3. RESEARCH PURPOSES: To know the history
of many chronic diseases like cancer, HTN
etc.
Screening may aid in obtaining more basic
knowledge about the natural history of such
diseases.
Initial screening provides a prevalence
estimate and subsequent screening provides
an incidence figure.
USES OF SCREENING
4. EDUCATIONAL OPPORTUNITIES:
Screening programmes help in Acquisition of
information of public health relevance.

Providing opportunities for creating public

awareness.

For educating health professionals.

TYPES OF SCREENING
1. 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.
Examples.
a) Visual defects in all school children
b) Mammography in women
c) Colonoscopy for occult blood.
TYPES OF SCREENING
2. HIGH RISK / SELECTIVE / TARGETED
SCREENING
 The screening of selected high-risk groups in
the population.
Examples:
a) Screening fetus for Down’s syndrome in a
mother who already has a baby with Down’s
syndrome
b) Screening for familial cancers, HTN and DM
c) Screening for CA Cervix in low SES women
d) Screening for HIV in risk groups.
TYPES OF SCREENING
3. MULTIPURPOSE SCREENING
 The screening of a population by more than
one test done simultaneously to detect more
than one disease
Examples:
a) screening of pregnant women for VDRL, HIV,
HBV by serological tests
TYPES OF SCREENING
4. MULTIPHASIC SCREENING
 The screening in which various diagnostic
procedures are employed during the same
screening program.
Examples:
a) DM – FBS, Glucose tolerance test
b) Sickle cell anemia – CBC, Hb electrophoresis
CRITERIA FOR SCREENING
 Before initiating a Screening Programme, a
decision must be made whether it abides to all
the ethical, scientific and financial justification.
 The principles that should govern the
introduction of screening programmes were
first enunciated by “Wilson and Junger “ (1968)
 The Criteria for Screening is based on two
considerations:
- DISEASE
- SCREENING TEST.
DISEASE CRITERIA
1. The Disease should be important Health
problem (High Prevalence)- Example TB
2. Disease should have Long & Detectable
Preclinical stage.
3. The Natural history of disease should be
adequately understood.
4. Appropriate test must be available for early
detection of disease (before signs and
symptoms appear)
DISEASE CRITERIA
5. Facilities must be available for diagnosis of
disease (Confirmation/ Gold standard)
6. Early detection of disease and treatment
should be able to reduce mortality &
Morbidity.
7. The disease should be treatable, and there
should be a recognized treatment for
lesions identified following screening.
8. Expected benefits must exceed risks and
costs.
SCREENING TEST CRITERIA
1. Inexpensive & Easy to Apply- (Simplicity)
2. Acceptable
3. Valid
4. Reliable
5. Yielding
1. SIMPLICITY
 The test should be
simple to perform,
easy to interpret
and where possible,
capable of use by
paramedics and
other personnel.
 Ex: Blood and urine
tests for early
detection of
diabetes
2. ACCEPTABLE

 Since participation in screening is voluntary,

the test must be acceptable to those
undergoing it.
 In general tests that are painful,
discomforting or embarrassing are not likely
to be acceptable.
 Ex: Screening for prostrate cancer might not
be acceptable to a large proportion of the
community.
3.VALID
 Validity determines the Accuracy of the
Test.
 It expresses the ability of a test to separate
those who have the disease from those who
do not.
 A test with little systematic error is a valid
test.
 Components of validity are-Sensitivity,
Specificity and Predictive Accuracy
SENSITIVITY
 The ability of a test to correctly identify
those who have the disease (True Positives)-
“Proportion of Truly Ill Population”

Disease Disease
Present Absent
Test Positive True Positive False Positive
(TP) (FP)
Test Negative False Negative True Negative
(FN) (TN)

Sensitivity is expressed as percentage;

TP/(TP+FN)X100%
SPECIFICITY
 The ability of a test to correctly identify
those who do not have the disease. (True
Negatives)-“Proportion of Truly Healthy
Population.”
Disease Disease
Present Absent
Test Positive True Positive False Positive
(TP) (FP)
Test Negative False Negative True Negative
(FN) (TN)

Specificity is expressed as percentage;

TN/(FP+TN)X100%
CALCULATION

Theoretically an ideal screening test should have 100%

sensitivity and 100% specificity. It is not practically
possible.
FALSE NEGATIVES AND FALSE
POSITIVES
 If a Person with disease is  If a Person without disease is
labeled Negative: labeled Positive:
 Impact:  Impact:
 - False reassurance  - Further testing with long,
 - Ignores any disease signs expensive tests.
and symptoms  - Discomfort, inconvenience,
 - Postponement of anxiety
treatment.  - Burden on health facilities
 - Detrimental to overall  - Emotional trauma
health  - Difficulty in “de-labeling”
 Found in, test having low  Found in, test having high
sensitivity and high sensitivity and low specificity
specificity
FALSE NEGATIVES FALSE POSITIVES
4. RELIABLE
 Reliability determines the Precision of the Test.
(Repeatability)
 It means that all the results of the test should be
similar (Cluster at one place), when conducted
each and every time.
 This is not possible because of the Variations that
cause the test to not yield same results every
time. (like Lab equipment failure etc.)
 3 types of Variation

a) - Intrasubject Variation
b) - Intraobserver Variation
c) - Interobserver Variation
RELIABILITY-INTRA SUBJECT
VARIATION
 This is the Variation
in the results of the
test conducted over
time (Short periods)
on the same
individual.
 The difference is
due to the changes
that occur to the Variation in BP during 24 hours
individual over that period among three individuals

time period.
RELIABILITY
 This is the Variation  This is the Variation
in the results of the in the results of the
test due to the same test due to the
observer examining multiple observers
the result at different examining the result.
times.  EX: Chest X ray read
 EX: Two readings of by two different
Blood pressure by the Radiologists.
Same observer.

Intra-observer variation Inter-observer variation

UNDERSTANDING VALIDITY AND
RELIABILITY
 VALIDITY IS THE
ACCURACY OF A TEST.
 RELIABILITY IS THE
PRECISION OF A TEST.
 ACCURACY: “how close
is result of a test to its
true value?”
 PRECISION: “how close
are the results of a
test on repetition?”
UNDERSTANDING-VALIDITY &
RELIABILITY
5. YIELDING
 Yield is the amount of previously
unrecognized disease that is detected and
brought to treatment as a result of
Screening.
 It depends on prevalence of the disease and
sensitivity of the screening test,
participation in the programme.
 Hence, yield of a screening test is high in
high – risk screening.
MULTIPLE TESTS-SEQUENTIAL TESTING (TWO
STAGE)

 After the first (screening) test is conducted,

those who tested positive are brought back
for the second test to further reduce false
positives.
 Consequently, the overall process will
increase specificity but with reduced
sensitivity.
 Net Sensitivity and Net Specificity can be
calculated for both the tests in sequence.
 Net sensitivity falls, but Net Specificity will
be gained.
MULTIPLE TESTS-SIMULTANEOUS
TESTING (PARALLEL TESTING)
 Two or More tests are conducted in parallel.
 The goal is to maximize the probability that
subjects with the disease (True Positives) are
identified.- High Sensitivity.
 Consequently more False Positives are also
identified.(Specificity Low)
 Net sensitivity is Gained, but Net Specificity
will be lost- when compared to either of the
tests.
PREDICTIVE ACCURACY
 The Proportion of the  The Proportion of the
people who is people who is
screened positive that screened negative
actually have the that are actually FREE
disease. of the disease.
 Are the people with  Are the people
disease correctly without disease
identified? correctly identified?

These Values are not fixed for a particular test.

Positive Predictive Values (PPV) Negative Predictive Values (NPV)

CALCULATION

PPV is expressed as percentage; TP/(TP+FP)X100%

NPV is expressed as percentage; TN/(TN+FN)X100%
PREDICTIVE ACCURACY
 Predictive accuracy depends on-
a) Prevalence of the Disease.
b) Specificity of the Test.
 More prevalent diseases has high PPV, that’s
why SCREENING is more efficient &
productive, If done in High risk population.
 Increase in Sensitivity causes a modest
increase in PPV, but increase in Specificity
raises PPV markedly.
CONCLUSION
 Screening is a major public Health determinant,
measured by its effect on Mortality, Morbidity
& Disability.
 Establishing appropriate criteria requires
considerable knowledge of the Natural history
of disease, adequate facilities for follow up &
treatment.
 It is necessary to ensure that the program is
continuously monitored to confirm that
effectiveness is maintained. (benefits>costs)
 Newer fields such as genetic screening are on
the rise which would help the cause.
THANK YOU