Screening

Learning objectives:
 Define screening
 Identify aims and objectives of screening.
 Explain differences between screening and diagnostic tests.
 Identify types and uses of screening.
 Recognize the criteria required to launch a screening program.
 Identify measures for evaluation of screening test.
 Define and calculate sensitivity, specificity, positive and negative predictive
values, percentage of false positive and percentage of false negative.
Definition of screening
 The search for unrecognized disease or defect by
means of rapidly applied tests, examinations or other
procedures to sort out apparently well persons who
probably have a disease from those who probably
do not.
 Definition of screening
 In passive case finding where patients come to
medical personnel with symptoms of disease, they are
examined carefully and investigated to be diagnosed.

 On the other hand, in screening, the medical team

examines persons without symptoms to detect risk
factors or early subclinical disease.
 Aims and objectives

 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.

 Screening is carried out in the hope that earlier diagnosis

and subsequent treatment favorably alters the natural
history of the disease in a significant proportion of those
who are identified as "positive".
Comparison between screening test
and diagnostic test:
Screening test Diagnostic test
Done on apparently Done on those with
healthy symptoms of disease
Used on groups Used on an individual basis.
Less accurate More accurate
Less expensive More expensive
Not a basis for treatment Used as a basis for
treatment
Types of screening:
 a) Mass screening
 b) High risk or selective screening
 c) Multi-phasic screening:
 Uses of screening
a) Case detection.

b) Control of disease.

c) Research purposes.
Criteria for instituting a screening program
 • Serious.
• High prevalence of pre-clinical stage.
Disease • Natural history understood.
• Long period between first signs and overt disease.

• Sensitive & specific (valid)

• Reliable (repeatable)
Screening test • Simple
• Low cost
• Safe and acceptable

Diagnosis & • Facilities are adequate.

treatment • Effective, acceptable and safe treatment available.
 Evaluation of screening test
I- Repeatability (or Reliability) of a screening test.

II- Validity (or accuracy) of screening test.

III- Yield of the test.

I- Repeatability (or Reliability) of a screening test

 A repeatable test is the test that gives the same results

if it is repeated many times on the same individual
under the same conditions, so repeatability is the
percent agreement between multiple results of the
test.
Variations in results of the test
?????
Variations in results of the test mean poor
repeatability. It may be due to:

1-Variation in the characteristic being measured.

2- Variation due to observer (tester).

3- Variations in instruments or methods.

 Measures to enhance repeatability
1- Clear operational definition of variables or cases.
2- Good training of data collectors.
3- Standardization of questions and tests.
4- Data collectors or observers should not be changed in
midstream.
5- Use of good and well-calibrated instruments.
 II- Validity (or accuracy) of screening test
 Validity expresses the ability of a test to separate or
distinguish those who have the disease from those who
do not.

 It is the degree to which the test measures what is

intended to measure.

 It is assessed by comparing the results of the used test

with an already accepted test (Valid test).
 Gold standard (Diagnostic test)

Screening(New test) Diseased Not diseased Total

Screening test
?? ?? Screening +ve
positive

Screening test
?? ?? Screening - ve
negative

Total Total dis. Total not dis. Grand total

 Sensitivity:
The probability of the screening test to be positive when the disease is truly present i.e.
the percent of those who have the disease and so indicated by the test.

True positive (a)

Sensitivity = ---------------------------------------------------------------- x 100
True positive (a) + False negative (c)

Persons with the disease detected by the screening test

i.e. Sensitivity= -------------------------------------------------------------------------- x 100
Total number of persons tested with the disease (validating test)
 Specificity:
The probability of the screening test to be negative when the disease is truly absent i.e. the
percent of those who do not have the disease and are so indicated by the test.

True negative (d)

Specificity = ------------------------------------------------------------ x 100
True negative (d) + False positive (b)

Persons without the disease who are negative by the screening test
i.e. Specificity = ---------------------------------------------------------------------------------- x 100
Total number of persons tested without the disease
The best screening test is one with high sensitivity and
specificity.
Positive predictive value:
It is the probability of the person having the disease
when the test is positive.
True positive (a)
Positive predictive value = -------------------------------------------
True positive (a) + False Positive (b)
 Negative predictive value:
It's the probability of the person not having the disease when the test in negative.

True negative (d)

Negative predictive value = -----------------------------------------------
True negative (d) + False negative (c)
 False negative (c)
Percentage of false negative = ---------------------------------------------
False negative (c) + True positive (a)

False positive (b)

Percentage of false positive = -------------------------------------------------
False Positive (b) + True negative (d)
 total number of cases (a+c)
Prevalence = ----------------------------------------------
grand total (a+b+C+d)
 Example 1
Diagnosis
Positive Negative Total
Screening
Positive 40 20 60
Negative 100 9840 9940
Total 140 9860 10000
Calculate:
1- Sensitivity.
2- Specificity.
3- Positive predictive value.
4- Negative predictive value.
 Example 2
 In a cancer cervix screening program, the screening test was positive in
1300 women and negative in 18700 women. Screening test was positive
only in 300 of the 400 confirmed cases.

◼ Draw a cross tabulation of these results.

◼ Calculate:
1- Sensitivity.
2- Specificity.
3- Positive predictive value.
4- Negative predictive value.
 Positive Negative Total
Positive 300 1000 1300
Negative 100 18600 18700
Total 400 19600 20000

300
Sensitivity = 400 × 100 = 75%
18600
Specificity=19600 × 100 = 94.9%
300
PPV= 1300 × 100 = 23.1%
18600
NPV=18700 × 100 = 99.5%
III- Yield of the test
 This is the amount of previously unrecognized disease,
which is diagnosed and brought to treatment as a result
of screening. It depends on sensitivity, specificity and
prevalence of the disease.

 The value of screening program is ultimately determined

by its effect on morbidity, mortality and disability.
Exercises:-
Choose the right answer:
1- A screening test must be:
 Simple, cheap and quick.
 Simple, expensive and accurate.

 Simple, cheap and slow.

 Highly accurate and can be slow

2- Repeatability mean that:
 The test will give the same result if repeated under the same condition.
 The test will be interpreted well.
 The test is acceptable.
 The test will give the same results under different conditions

3- Sensitivity is the ability of the test to:

 Detect all positive cases.
 Detect false positive cases.
 Detect false negative cases.
4- The good definition of the disease:
 Decreases patient's error.
 Decreases tester's error.
 Doesn't affect errors.

5- Low cost is a character of:

 Screening test.
 Diagnostic test.
 Both.
Problem No. 1:
A new screening test for a certain disease is being
evaluated. The results were a demonstrated to 580
persons, 90 of whom are known to have the disease. This
test was found to be positive in 70 of the 90 people with
the disease as well as 30 who do not have the disease.
 Diseased Not diseased Total

+ ve 70 (TP) 30 (FP) 100

- ve 20 (FN) 460 (TN) 480

Total 90 490 580

Calculate:

70
 Sensitivity = × 100 = 77.8%
90

460
 Specificity= × 100 = 93.9%
490

30
 % FP = × 100 = 6.1% ; = 100- specificity
490

20
 % FN= × 100 = 22.2% ; = 100- sensitivity
90
Calculate:

90
 Prevalence of the disease = × 100 = 15.5 %
580

70
 PPV= × 100 = 70.0%
100

460
 NPV= × 100 = 95.8%
480
 Problem No. 2:
Two screening tests, A and B are available for one disease.
The sensitivity and specificity of each test are shown below:

TestA Test B

Sensitivity 90% 60%

Specificity 70% 80%

a- Which test produce the greater percent of false
negative?

b- Which test produce the greater percent of false

positive?
Two screening tests, A and B are available for one disease.
The sensitivity and specificity of each test are shown below:

TestA Test B
Sensitivity
100- Sensitivity= 90% = 10 60% =40
%FN
Specificity
100- Specificity= 70% =30 80% = 20
%FP
a- Which test produce the greater percent of false
negative?
Test B

b- Which test produce the greater percent of false

positive?
Test A
2- When sensitivity increase, the number of false
negative (FN) decreases

3- To launch a screening program for certain diseases.

The disease fulfill the following criteria.
 Serious.
 High prevalence of pre-clinical stage.
 Natural history understood.
 Long period between first signs and overt disease.
4- The following are measures to enhance
repeatability of a screening test:
 Clear operational definition of variables or cases.
 Good training of data collectors.

 Standardization of questions and tests.

 Data collectors or observers should not be changed in

midstream.
 Use of good and well-calibrated instruments.
Thank you