Screening &

Surveillance
Dr. Ali Alamin
Hanan Almaimani
20233
 Screening for disease
It has been defined as “search for unrecognized
disease or defect by means of rapidly applied tests,
examinations or other procedures in apparently
healthy individuals”.
Example:
● Screening of tuberculosis
● Syphilis
● Antenatal mothers
● School children
● Occupational groups
 Screening :

so
1. Capable of wide applications.

2. Relatively in expensive.

3. Requires little physician time.

4. An initial examination.

5. Those who are positive, referred to physician

for further diagnostic tests.
 Screening and Diagnostic tests
contrasted.
Screening test Diagnostic test

1 Done on apparently healthy. Done on those with indications or sick.

2 Applied to groups. Applied to single patients, all disease are considered.

3 Test results are arbitrary and final. Diagnosis id not final but modified in light of new
evidence. Diagnosis is the sum of all evidence.

4 Based on one criterion or cut-off point (e.g. diabetes). Based on evaluation of a number of symptoms, signs and
laboratory findings.

5 Less accurate. More accurate.

6 Less expensive. More expensive.

7 Not a basis for treatment. Used ad a basis for treatment.

8 The initiative comes from the investigator or agency The initiative comes from a patient with a complaint.
providing care.
or
 Aims & objectives:

1. The 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
disease under study.
2. To bring those who are apparently abnormal
under medical care and treatment.
3. It is carried out to have early diagnosis &
treatment.
 Screening
O
Screening: It is testing for infection or disease in the
populations or in individuals who are not seeking health
care. o
Ex: Serological tests for HIV/AIDS.
Neonatal screening

É
Premarital screening for syphilis
Case finding : Clinical or laboratory test to detect
disease in individuals seeking health care for other
reasons. j
Ex: VDRL test for syphilis in pregnant women.
Hypertensions.
Cervical cancer.
 Diagnostic tests

se
Hey
Diagnostic tests: Clinical or laboratory procedures
to confirm or refute the existence of disease or true
a 0 patients with signs & symptoms
abnormality in the
In
presumed to be caused by the disease.

Ex: VDRL testing suggestive of secondary syphilis.

 Uses of screening:
to
1. Case detection :
Ex : Bacteuria in pregnancy
Breast cancer
Cervical cancer
Diabetes
Iron deficiency anaemia
TB
 Uses of screening:

2. Control of disease:
It is prospective screening.
Ex:
• Screening of immigrants from infectious disease. ex :
syphilis & TB
• Screening of streptococcal infectious to prevent
rheumatic fever .
3. Research purpose.
4. Educational opportunities.

jaws
 Types of screening.
Three types
1. Mass screening.
Ex: Mass screening TB
2. High risk or selective screening.
Ex: Screening of lower social groups for cancer cervix.
Elevated serum cholesterol to coronary heart disease.
3. Multiphase screening: Applications of two or more screening
tests in combinations to a larger number of people at one
time than to carry out separately.
Ex: Chemical & hematological tests on blood and urine
Lung functions tests
Audiometry and measurement of visual acuity
 WHIP
Criteria for screening

It is based on two considerations in disease to be screened

and test to be applied.
First consideration:
Disease: The disease should fulfill the following criteria:
● The condition should be an important health problem
(prevalence should be high).
● Should be recognizable latent or early asymptomatic.
● Natural history of the conditions should be adequately
understood.
● There is a test that can detect the disease prior to onset of
signs & symptoms.
 Cont.

● Facilities should be available for confirmation of the

diagnosis.
● There is a effective treatment.
● There should be an agreed-On policy concerning whom to
treat as patients.
Ex: Lower range of blood pressure, border line diabetes.
● There is a good evidence that early detection and treatment
reduces morbidity & mortality.
● The expected benefits of early detection exceed the risk and
costs.
 Screening tests
Second consideration :
Screening test: The test must satisfy the criteria of acceptability,
repeatability and validity with an yield, simplicity, safety,
rapidity, ease of administration and cost.
•Acceptability: In general tests may be painful, discomfort or
embracing.
•Repeatability: The test must give consistent results when
repeated more than once on the same individual or material,
under the same conditions.
 Repeatability depends on three
major factors
● Observer variations:
1.
2.
of
Intra observer variations. Ex: BP, chest measurements
Inter observer variations. The variations between different
observer on the same subject or material. Ex: x-ray reading, ECG,
BP.
● Biological variation:
• Associated with physiological variables, blood pressure, blood sugar,
Cholesterol
• Changes in parameters: One site negative another positive.
• Variations in the recollection of past events.
• Regression to the mean. Ex: BP, blood sugar
● Errors relating to technical methods
 Validity (accuracy)

Validity expresses the ability of a test to separate and

distinguish those who have disease from those who
so
do not
Ex : glucose tolerance test for diabetes
It got two components:
●Sensitivity: The ability of a test to identify correctly
all those who have disease. true positives.
●Specificity: The ability of a test to identify correctly
those who do not have the disease: true negatives.
Sensitivity and specificity determined by applying the
test to one group of person having the disease, and to a
reference group not having disease.
t
Sensitivity = a /a + c x 100
Specificity = d / b + d x 100 x

Predictive value of a positive test = a / a + b x 100

Predictive value of a negative test = d / c + d x 100
Percentage of false negatives = c / a + c x 100
Percentage of false positives = b / b + d x 100
x
• Among 100 patients with Alziemer’s disease 15
subjects scored within the normal range on a battery
of tests of cognitive performance.
Screening test Diagnosis Total
results
Disease + xNot disease -

Test positive + a b

Test negative - c (15) d

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

• Among 500 persons with +ve screening tests for
antibodies to the HIV;492 are infected with virus
Screening test Diagnosis Total
results
Disease + x
Not disease -

Test positive + a (492) b a+b (500)

Test negative - c d c+d

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

• Among 1000 women without breast cancer, screening
mammogram are normal for 920 women
Screening test Diagnosis Total
results
Disease + Not disease -
x
Test positive + a b a+b

Test negative - c d(920) c+d

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

• Among 750 patients with normal screening test result for
serum cholesterol, 50 actually have elevated serum
cholesterol.
Screening test Diagnosis Total
results
Disease + Not disease -

Test positive + t a b a+b

Test negative - c(50) d c+d(750)

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

a. Sensitivity.
b. Specificity.
c. % false positive.
x
d. % false Negative.
e. Predictive value of +ve test.
f. Predictive value of negative test.
 Diagnosis of brain tumor by EEG

EEG results Brain tumor

Present Absent

Positive 36 54.000

Negative 4 306.000

40 360.000

Sensitivity =36/40X100= 90%

Specificity= 306.000/360.000X100= 85%

Diagnosis of brain tumor by computer assisted axial tomography

CAT results Brain tumor

Present Absent

Positive 39 18.000

Negative 1 342.000

40 360.000

Sensitivity =39/40X100= 97.5%

Specificity= 342.000/360.000X100= 95%
 I IDI
Predictive accuracy

• It will give the diagnostic power of the test.

0
• It depends on sensitivity, specificity & disease
prevalence.
• The predictive value of a positive test indicates the
probability that a patient with a positive test
• More prevalence of a disease in population, the more
accurate the predictive value of a positive screening
test.
 Prevalence 5%
Smear Culture Total
• Predictive value of a positive-
gram stained cervical smear test Positive Negative
(with constant sensitivity of Positive +25 95 120
50% and specificity of 90%) at Negative -25 855 880
three levels of prevalence. x 50 950 1000
Prevalence 15% Positive predictive value: 25/120X100/1= 21%
Smear Culture Total
Prevalence 25%

Positive Negative Smear Culture Total

Positive +75 85 160

Positive Negative
Negative -75 765 840
Positive +125 75 200
150 850 1000
Negative -125 675 800
Positive predictive value: 75/160X100/1= 47%
250 750 1000
Positive predictive value: 125/200X100/1= 63%
 False negative and false positive

False negative: False negatives means that patients

who actually have the disease are told that they do not
have the disease.
The lower the sensitivity, the larger will be the
number of false negatives.

False positives: False positive means that they

patients who do not have the disease are told that they
have. A screening test with a high specificity will
have few false positives.
it
Yield: It is the amount of previously unrecognized
disease that is diagnosed as a result of screening
effect. Ex : Diabetes after 40 yrs.

Combinations of tests: Syphilis screening 1st to RPR

test, then we yield false positives -x FTA – ABS- more
specificity test, true syphilis

The problem of borderline case.

x
 Important points in screening test
1. 1 It must be applied selectively to those people most likely to
benefit .
Ex: Cervical cancer cytology
Age
Sex
Medical history
Occupation
Family history etc.
2. Tests with greater accuracy may be more expensive and time
2
consumption.
3. It should not be isolation, but it should be integrated in to
3 existing health services.
4. Risks and benefits must be explained.
 Evaluation of screening
programmers
1. RCT – When disease has low frequency with
long incubation period.
2. Uncontrolled trails – Ex : Cervical cancer pap
smear
3. Other methods:
a. Case control studies
b. Comparison trends between areas.
 Test
1. Randomizations is a statistical procedure by which
participants are allocated in to groups in study & control
groups.
2. In analytical studies there is no randomization because
diseased and non diseased groups already taken place.
3. Manipulation is deliberate applications
x or withdrawal or
reductions of the suspected factors.
4. RR = rate in exposed/rate in unexposed.
5. ARR( absolute risk reduction) = absolute value of (rate
in exposed – rate in unexposed)
6. NNT(No. needed for treatment) = 1 / ARR
 Test cont.

7. Sensitivity is the ability of a test to identify correctly all

those who have disease- true negatives.
8. Specificity – The ability of a test to identify correctly those
who do not have the disease - true negatives.
9. In Cohort Study presence or absence of risk factor is
determined before outcome occurs.
10. Attributable risk is the No. of cases among the exposed
that could be eliminated if the exposure were removed=
(Incidence in exposed - Incidence in unexposed).
 Case control study
Screening for GERD Total
obesity
+ -
x
Obese + 180 70

None obese - 70 180

Total 250 250 a+b+c+

d
• Incidence among exposed 180/250*100
• Incidence among not exposed=70/250*100 odds ratio= ad/bc = 6.1
 Cohort Study
• Smokers =250, Non Smokers = 250
• Among smokers 100 lung cancer after 20 years.
• Among non-smokers 10 lung cancer after 20 years.

Testing for Lung Cancer Total

smoking
+ x -
Smokers+ 100 150 250
None smokers - 10 240 250

Total 110 390 500

• Relative risk= incidence among exposed/incidence among not exposed
• Relative risk= 100/250/10/250== 100/10=10
Questions
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