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Screening definition concepts and lead

time

 ICEBERG PHENOMENON OF DISEASES:

 Visible cases – clinical illness and death (cases seen by the

physician in the hospital or clinician)
 Below the line hidden portion – asymptomatic cases

Subclinical cases
Undiagnosed cases
- These cases reflect majority of the burden of diseases seen by
public health specialist.
AIM: To find out the burden of the disease, if we somehow able to
find out the burden of disease and treat = we will have a healthy
population.
Q: how do you achieve this aim?
- By SCREENING:
To search for unrecognized disease on defect by means of
rapidly applied tests, examinations on other procedures in apparently
healthy individuals
 - Unrecognized disease – submerged part of iceberg that we are
aiming at
- Rapidly applied tests – applied on a larger population,
everybody in the population has to be tested
- Apparently healthy individuals – screening is directed towards
people who are apparently healthy.

Q: What is the difference between screening and diagnostic test?

SCREENING TEST DIAGNOSTIC TEST
1. Done on apparently healthy 1. Individuals with signs and
individuals symptoms of disease or any
other indication of disease

2. Applied on groups, population 2. Applied to single patient

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Why?(cause u need to filter out
likely patients)

3. Test results are arbitrary and 3. Test results are not final
final (test results are reviewed in the
What does it mean? -we fix a light of other evidence like signs
arbitrary cut-off Ex: 140mmHg and symptoms and
cut off for systolic BP epidemiological features
>140mmHg - +ve list
<140mmHg - -ve list
Misclassification
Arbitrary cut off has to be fixed
because test has to be applied on
a large population and we need
more than one investigation for
applying the test – so uniform
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cutoff has to be fixed, so that

results are valid

What is final? - Test results are

final for that particular time for
making a list of +ve and –ve.

4. Based on one criteria 4. Based on complete clinical

(ex: systolic BP cut off 140mmHg) picture(signs, symptoms and lab
findings)
5. less accurate(the purpose of
screening test is to filter out the 5. More accurate
likely patients who will be (forms basis of rx)
further evaluated for diagnosis)

6. less expensive ( applied on

mass /larger population and
rapidly applied as well)
7. Relatively rapid
8. Does not form basis for
treatment
9. Initiative from the agency
(owner of a factory , NGO,govt)
6. More expensive( does not
necessarily be a rapidly applied
test)
7. Time consuming
8. Basis of treatment (in
combination of complete clinical
picture)
9. Initiative from the patient
(with signs and symptoms)

Q: why to do screening in a person who is appearing healthy?

- For the purpose of early detection of disease, better treatment,
better prognosis, better chances of survival.
A – Disease onset
B- First possible point of diagnosis
C- First critical point in the disease (some irreversible damage has
already occurred after which treatment may not give the desired
benefit)
Ex: diabetes – first possible point of diagnosis would be screening by
GTT can recognise the disease.
-1st critical point – onset of early diabetic retinopathy
-Usual time of diagnosis – pt presents with some difficulty in vision
and that time when BP isAfraTafreeh.com
done the person is found to be diabetic.
0 – diabetic retinopathy has occurred
- If screening was introduced at the earliest point I.e point B and
by regular control of blood sugar and Rx of diabetic retinopathy
could be prevented.
- The new outcome N – lead time.

 LEAD time: time from first possible point of diagnosis to the

usual time of diagnosis is the LEAD TIME i.e. the lead you gain
because you had screening test in position.
Q: To be effective ST should ideally be applied b/w which two points?
A and B / Band C / C and D
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?b/w A and B – no (nothing can detect the disease before first point
of diagnosis
?b/w C and D – no use if critical point passed
- Best applied b/w B and C – possibility to alter outcome of the
disease.
- The usual time of diagnosis is D but had the disease been
detected at B by use of some screening test, we could have
altered the outcome of the disease.
- Gap b/w B and D = LEAD TIME

- How much you are leading the time of detection of disease =

advantage gained by a screening test
- Diseases which have a significantly long lead time – gain from a
screening program.
- Prevalence – 1/million

- Prevalence – 0.1/million
 Criteria, scope, type of disease and tools
for screening, example from NHP

Q: what should be the criteria for selection of disease and its

screening tool?

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 SCOPE OF SCREENING:

1.CASE DETECTION: identifying cases of disease from apparently

healthy population.
‘PRESCRIPTIVE SCREENING’
-screening the people for their own benefit
EX: PAP smear

2. CONTROL OF DISEASE – screening people for others benefit

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‘PROSPECTIVE SCREENING’
Ex: using screening immigrants for diseases that are not present in
home population and if they are +ve either quarantine or Rx to
prevent an outbreak of that disease.

3. RESEARCH - prevalence of a particular disease

- To provide estimates of prevalence of disease and
other parameters.
4. EDUCATIONAL OPPURTUNITIES – knowing is believing
- Once the people know that certain diseases exist among the
community members, it becomes easier to educate them about
their method of prevention.

 TYPES OF SCREENING:
1. Mass screening – apply screening test to everyone in the
population or subgroups of population irrespective of the fact
whether the person has the risk factor or does not have.
Ex: measure BP of all members of defined population and
identifying hypertensive among them.
- Breast examination of all adult women for breast cancer.
- Less efficient
 2. High risk selective screening:
Applied to a group who are at high risk of developing
the disease in question.
Ex: screening for CVD: elderly, postmenopausal women.
Breast cancer - +ve family history of breast cancer
- most efficient –selective screening of high risk group
- most cost effective – carcinoma cervix

3. Multiphasic screening :-
When two or more screening tests are applied together to
assess disease status at the same time
Ex: undernourishment can be assessed through physical examination,
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anthropometric examination, and lab investigations- blood tests

 HIV – ERS –ELISA, rapid, simple

 Breast cancer – breast self-examination
 Oral cancers – bimanual oral examination
 Prostate cancer – digital rectal examination
 National health programs:
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Screening test Diagnostic test

TB Cough >2 weeks Sputum smear
examination,
CBNAAT,LPA
Malaria Any case of fever PBS for malarial
parasite

LEPROSY Hyperaesthetic Clinical diagnosis

lesion (examination of
skin lesion)
 Properties of screening test, validity,
sensitivity, specificity, PPV, NPV

Q. How do we decide which screening test is best?

1. ACCEPTABILITY
2. REPEATIBILITY
3. VALIDITY

1 .ACCEPTABILITY:

In apparently healthy individuals

- High rate of cooperation needed especially from apparently
healthy people AfraTafreeh.com
- Not be painful
- Not be embarrassing
- Not be discomforting

2. REPEATIBILITY :- (reliability, precision)

-consistency in reproducibility
- Test must give same (consistent) results when repeated more
than once on same individual on sample under same
conditions.
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Depends on 3 major factors:-

1. Observer variation
2 .biological variation

3. Errors due to technical methods

1. Observer variation: a. intraobserver

b.interobserver
A. Intraobserver : variations b/w repeated observation by same
observer or same subject at same time.
Height of a same person 3 times
- Within observer variation :-
- minimized: take average of all findings

B. INTEROBSERVATION VARIATION :
Between observer – 2 different observes takes same
measurement in same person. - possibility of giving different results
- Minimization – standardization of test procedures and impart
training and skills.
- EX: interpretation of X-rays, ECG training, histopathological
studies.

2.BIOLOGICAL VARIATION : certain body parameters follow diurnal

rhythms so there could be difference in measurement of measured
during different times of the day.
3 .TECHNICAL ERRORS:

Instrument is malfunction.

 VALIDITY of a screening test :

(To what extent the test measures what it is supposed to
measure) = accuracy of measurement
(in other words it is the ability of a test to differentiate diseases cases
from non-diseases cases)
 SENSITIVITY
 SPECIFICITY are the 2 components of validity of a test
DISEASE
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Screening test Present absent
Positive A B
negative c d

A - True positive: - population having the disease and screening

test results are positive.
d - True negative: population not having the disease and the results
of screening test are also negative

B –false positive – population not having the disease but screening

test result is positive
C - False negative –population having the disease but ST results is
–ve.
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 Total population having the disease – a+c (TP+FN)

 Total population not having the disease – b+d (FP+TN)
 Results of a screening test – evaluated

1. SENSITIVITY: ability of a screening test to identify correctly all

these who have the disease.
Sensitivity = a/a+cx100 =TP/TP+FN
- ex :80%
If a test is done on 100 diseases people test will come positive
only in 80 people and remaining will get a false negative result.
A 80% sensitivity means that 80% of diseases people screened by the
test will give a true positive result and remaining 20% will give a false
negative result.

2. SPECIFICITY : ability of a ST to identify correctly all those who do

not have the disease I.e. true negatives
Specificity =d/b+dx100 = TN/FP+TN
- 80% - if these tests is done on 100 healthy people the test will come
–ve in 80 people and remaining 20 people will get a false positive
result
- 80% non-diseases people screened by the test will give true
negative result and 10 % non-diseased people screened by the
test will be wrongly classified and diseased I.e. FP
 3. POSITIVE PREDICTIVE VALUE : ability of a test to identify
correctly all those who have the disease out of all those who
tested +ve on a screening test
PPV = a/a+bx100 = TP/TP+FPx100
- Person with a +ve test result in fact has the disease in question
- PPV of a screening test is directly proportional to the prevalence
of disease in the population

4. NEGATIVE PREDICTIVE VALUE:

ability of a test to identify
correctly those who do not have
the disease, out of all those tested as –ve.
NPV = d/c+d x100 = TN/FN+TN
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 ACCURACY OF A SCREENING TEST :

= a+d/a+b+c+d = correct result/total result
Disease (cervical cancer)
PAP Smear present absent total
+ve 80 100 180
-ve 20 800 820
Total 100 900 1000

SENSITIVITY (TP) = a/a+cx100 = 80/100x100 = 80%

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Out of 100 women having cervical cancer, PAP smear will come +ve in
only 80 of them and 20 will be reported falsely negative

SPECIFICITY (TN) = b/b+dx100

= 800/900x100 = 89%
Out of 100 women who are healthy PAP smear will come –ve in only
89 of them, other will be reported as falsely +ve.

PPV = a/a+bx100
=80/180x100 = 44.44%
Out of total +ve, only 44.44 % actually have cervical cancer

NPV = d/c+dx100
= 800/820x100 = 97.56%
Out of total tested negative 97.56% do not have the disease.

Q: sensitivity: - 1 –TP
1-TN
1-FP
1-FN
Sensitivity directly proportional to TP
Inversely proportional to false negative
Test result present absent
 +ve 80 100
-ve 10 800

Sensitivity : a/a+c = 80/100x100 =80%

False negative – sensitivity inversely false negative
-Sensitivity =1-false negative
-Specificity – directly proportional to true negative
Inversely proportional to false positive
1-FP

Q: screening tests in series or in parallel

Series: - a population is subjected to one screening test followed by a
2nd screening test AfraTafreeh.com
-2nd screening test is applied on those individuals only who test =ve on
1st screening test.
Ex:-
Sensitivity of RBS – 90%
Sensitivity of FBS – 90%
If I use RBS out of 100 diabetics, 90 will come +ve - I apply FBS only on
those who come +ve = 90% of 90
=90/100x90 =81+ve
-in series sensitivity of a test decreases
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 PARALLEL – A population is subjected to two on more screening

tests at the same time, each of the individuals is subjected to
both (on all) screening tests.
 100 diabetics – RBS (90+ve)
FBS (90+ve)

Sensitivity increases
SERIES PARALLEL
Sensitivity Decreases Increases
Specificity Increases Decreases
PPV Increases Decreases
NPV decreases increases

 BAYE’s THEOREM:
PPV = (sensitivity x prevalence)/ (sensitivity x prevalence) + (1-
specificity) (1-prevalence) x100