Screening for disease

Iceberg phenomenon of disease

 SCREENING FOR DISEASE

The presumptive identification of

unrecognized disease or defect by the application
of tests, examinations or other procedures
which can be applied rapidly in apparently
healthy individuals
 Screening Test Diagnostic test
1. Done on apparently 1. Done on those with
healthy indications or sick.
2. Applied to groups 2. Applied to single
patients
3. Test results are arbitrary 3. Diagnosis is the sum of
& final all evidence
4. Based on one criterion or 4. Based on evaluation of
cut-off point s/s & lab findings
Screening Test Diagnostic test
5. Less accurate 5. More accurate

6. Less expensive 6. More expensive

7. Not a basis for t/t 7. Used as a basis for t/t

8. Initiative : investigator or
8. Initiative : patients
agency providing care.

No hard & fast rules

 CONCEPT OF LEAD TIME

First possible Final Critical Usual time

point Diagnosis of diagnosis

Disease onset
detection Outcome
A

B
Screening Time

Lead Time
 CONCEPT OF LEAD TIME

Lead time –
advantage gained by screening i.e. period
between diagnosis by early detection &
diagnosis by other means .
Benefits of programme : B - A
Consider costs
 What is the objective of screening?

- To sort out those who are ‘likely to have disease’

from a large group of apparently healthy

- To bring those who are ‘apparently abnormal’

under medical supervision & treatment.

Provison : Early diagnosis & T/T alters the natural

H/O disease.
 USES OF SCREENING

a) Case Detection (Prescriptive Screening) –

does not arise from pt’s request.
e.g. bacteriuria in pregnancy, breast ca, DM
Pt screened for own benefit

b) Control of disease – benefit of others

e.g. screening of immigrants for TB
 USES OF SCREENING

c) Research purposes – more basic

knowledge about natural history e.g
deafness in children, diabetes, iron
deficiency anemia, pul. TB,
d) Educational opportunities – Creates
public awareness & for educating
health professionals.
 TYPES OF SCREENING

(a) Mass screening

(b) High risk or selective screening: SE class,
family, risk factors
(c) Multiphasic screening – Application of
two or more screening tests in
combination at one time .
(d) Multistage and combination of tests
Thank you!!!
 Criteria for screening
• Disease

• Test
 Criteria for screening- Disease
1. Important public health problem
2. Recognizable latent or early asymptomatic stage
3. Natural h/o the condition should be adequately
understood.
4. Availability of the test to detect disease prior to
the onset of s/s.
5. Availability of facilities to confirm disease
 Criteria for screening- Disease
6. Availability effective treatment
7. Agreed policy concerning whom to treat
as patients.
8. Good evidence that early detection &
treatment reduces morbidity & mortality
9. Expected benefits of early detection
exceed the risks & costs.
 Criteria : SCREENING TESTS

1. Acceptability
2. Repeatability/reliability
3. Validity
4. Yield, simplicity, safety, rapidity, ease
of administration, cost
Reliable but not valid
Reliable and valid
Neither reliable nor valid
Repeatability (Reliability, precision or reproducibility)

Depends on – observer, biological ,technical or instrument

(a) Observer variation : Intra – observer, Inter –
observer
Observer errors can be minimized by
- Standardization of procedures
- Intensive training
- Making use of  2 observers or independent
assessment
 Repeatability

(b) Biological / subject variation – Fluctuation

in the Variate
(i)Changes in the parameters observed
(ii)Variations in the way patients perceive
their symptoms & answer
(iii)Regression to the mean
Biological variation can be checked by
repeat measurements over time.
 Repeatability

(c) Errors relating to technical methods –

Defective instruments, erroneous calibration,
faulty reagents, test may be inappropriate.
 Validity
Validity (accuracy) – The extent to which the
test accurately measures what it purports to
measure.
- should provide a good preliminary indication
of which individuals actually have the
disease & which do not
- estimated by its sensitivity & specificity.
 Screening test result by diagnosis
Screening Diagnosis Total
Test Diseased Not Diseased
Results
Positive a b
(True positive) (False positive) a+b
Negative c d
(False Negative) (True negative) c+d

Total a+c b+d a+b+c+d

 Sensitivity
Screening Diagnosis Total
Test Results Diseased Not Diseased
Positive a b
(True positive) (False positive) a+b
Negative c d
(False Negative) (True negative) c+d
Total a+c b+d a+b+c+d

Sensitivity –
The ability of a test to identify correctly all those
who have the disease that is “true +ve”.
= a x 100
a+c
 Specificity
Screening Diagnosis Total
Test Results Diseased Not Diseased
Positive a b
(True positive) (False positive) a+b
Negative c d
(False Negative) (True negative) c+d
Total a+c b+d a+b+c+d

Specificity –
Ability of the test to identify correctly those who do
not have the disease “true -ve”.
= d x 100
b+d
 Positive Predictive Value(PPV)
Screening Diagnosis Total
Test Results Diseased Not Diseased
Positive a b
(True positive) (False positive) a+b
Negative c d
(False Negative) (True negative) c+d
Total a+c b+d a+b+c+d

Predictive value of a positive test(PPV or Post test

probability)
The probability that a person with a +ve result has , in
fact, the disease in question
a x100
a+b
 Negative Predictive Value(NPV)
Screening Diagnosis Total
Test Results Diseased Not Diseased
Positive a b
(True positive) (False positive) a+b
Negative c d
(False Negative) (True negative) c+d
Total a+c b+d a+b+c+d

Predictive value of a negative test –

The probability that a person with a -ve result does not
have , in fact, the disease in question
d x100
c+d
 Predictive accuracy

Depends on – sensitivity
- specificity
- prevalence(Pre test
Probability)
 Proportion of False +ve & False-ve
Screening Diagnosis Total
Test Results Diseased Not Diseased
Positive a b
(True positive) (False positive) a+b
Negative c d
(False Negative) (True negative) c+d
Total a+c b+d a+b+c+d

a) % of false –ve = c/a+c x 100

a) % of false +ve = b/b+d x 100

 False +ve & -ve
• False –ve : may ignore
High sensitivity↓

• False +ve : anxiety, further tests

high specificity↓
In a study it was found that EEG result was
Positive in 36 of 40 cases of brain tumor, while it
was positive even in 54000 of 3,60,000 persons
who did not have brain tumor. Calculate
sensitivity and specificity of EEG as a screening
tool for brain tumor. What is the % of false
positives & false negatives?
 Brain tumors by EEG :sensitivity & specificity

EEG Brain Tumor

Result
Present Absent Total
Positive 36 (a) 54,000 (b) 54036
Negative 04 (c) 3,06,000 (d) 306004
Total 40(a+c) 3,60,000(b+d) 3,60,040

Sensitivity = a/a+c
Specificity = d/b+d
False –ve = c/a+c
False +ve = b’b+d
 Brain tumors by EEG :sensitivity & specificity

EEG Brain Tumor

Result
Present Absent Total
Positive 36 (a) 54,000 (b) 54036
Negative 04 (c) 3,06,000 (d) 306004
Total 40(a+c) 3,60,000(b+d) 3,60,040

Sensitivity = a/a+c = 36/40 x 100 = 90%

Specificity = d/b+d = 306000/360000 x 100 = 85%
False –ve =4/40 x 100 = 10 %
False +ve =54000/3,60,000 x 100 = 15%
Brain tumor by CT : sensitivity & specificity
CT Brain Tumor Total
Result Present Absent
Positive 39(a) 18,000(b) 18039
Negative 1(c) 3,42,000(d) 3,42,001
Total 40 3,60,000 3,60,040

Sensitivity = 39/40 x 100 = 97.5%

Specificity = 3,42,000/3,60,000 x 100 = 95%
False –ve =1/40 x 100 = 2.5%
False +ve =18000/3,60,000 x 100 = 5%
 Predictive accuracy
• Reflects diagnostic power of the test
• Predictive value of a positive test
The probability that a person with a +ve result
has , in fact, the disease in question
• Predictive value of a negative test
Depends on – sensitivity
- specificity
- prevalence
 Predictive value

Screening Diagnosis Total

Test Results
Diseased Not Diseased

Positive a b a+b
(True positive) (False positive)

Negative c d c+d
(False Negative) (True negative)

Total a+c b+d a+b+c+d

a) Predictive value of a +ve test = a/a+b x 100(PPV)

b) Predictive value of a –ve test = d/c+d x 100(NPV)
 Example for calculating validity of a screening test :-

Result of the test Disease Total

Present Absent
Positive 160 (a) 80 (b) 240 (a+b)
Negative 40 (c) 720 (d) 760 (c+d)

Total 200 (a+c) 800 (b+d) 1000 (a+b+c+d)

Sensitivity = a / a+c x 100 = 160/200 x 100 = 80%

Specificity = d/b+d x 100 = 720/800 x 100 = 90%
Predictive power of the positive test = a/a+b = 160/240 = 0.66 or 66%
Predictive power of the negative test = d/c+d = 720/760 = 0.94 or 94%
 Predictive value of a test & prevalence of the disease
(sensitivity = 90% & specificity = 80%)
Prevalence= 10%
Result of the test Disease Total
Yes No
Yes
No

Total 1000
 Predictive value of a test & prevalence of the disease
(sensitivity = 90% & specificity = 80%)
Prevalence= 10%
Result of the test Disease Total
Yes No
Yes
No

Total 100 900 1000

 Predictive value of a test & prevalence of the disease
(sensitivity = 90% & specificity = 80%)
Prevalence= 10%
Result of the test Disease Total
Yes No
Yes 90 (a) 180(b) 270(a+b)
No 10 (c) 720 (d) 730(c+d)

Total 100(a+c) 900(b+d) 1000

Predictive Power –
Positive test = a/a=b = 90/270 x 100 = 33 %
Negative = d/c+d = 720/730 x 100 = 98%
 Predictive value of a test & prevalence of the disease
(sensitivity = 90% & specificity = 80%)
Prevalence 20%

Result of the test Disease Total

Yes No
Yes 180 160 340
No 20 640 660
Total 200 800 1000

Positive test = 180/340 x 100 = 52%

Negative test = 640/660 x 100 = 96%
 Yield
• The amount of previously unrecognised
disease
• depends on
– Sensitivity & specificity
– prevalence
– peoples participation.
• How to ↑
 Problem of borderline
• Cut offs in bimodal & unimodal
distribution
• Factors
– Disease prevalence
– Disease characteristic
 SCREENING TESTS (cont…)

Area
of Screening level set here
N over Poor sensitivity
lap Good specificity
U
M ‘A’
B Non glaucomatous
eyes
E Screening level – good sensitivity
R & poor specificity

‘B’ glaucomatous eyes

14 16 18 20 22 24 26 28 30 32 34 36 38 40 42

Intraocular pressure in MM of Hg
 Factors in screening
• Persons participating may not be those most
likely to gain
• Accuracy vs cost & time
• Screening to be integrated with health services
• Risk benefit to be explained
Thank you!!!