IX.

SCREENING IN DISEASE
CONTROL

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 SCREENING
I. Definition
• is the presumptive identification of
unrecognized disease or defect by applying
tests, examinations or other procedures which
can be applied rapidly.

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Diseases appropriate for screening:

 Disease should be serious.

 Treatment given before symptoms develop should be
more beneficial (reducing morbidity and mortality).
 The prevalence of preclinical disease should be high.

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Criteria for establishing screening program

• The problem to be detected should be important

enough to be worth detecting.

• The intervention should be feasible and available.

• There should be an acceptable intervention which is

effective.

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Criteria for establishing screening…

• There should be a suitable test.

• The test should be acceptable to the population to

be tested.

• There should be an agreed policy regarding when the

intervention is appropriate.

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Criteria for establishing screening…

Criteria for establishing screening…

• The cost of detecting the problem and its remedy

should be reasonable.

• The screening program should be ongoing,

and not a "one-time“ effort.

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The aim of screening program includes:

• To reverse, halt, or slow the progression of

disease more effectively than would probably
normally happen.
• To alter the natural course of disease for a
better outcome for individuals affected.
• Protect society from contagious disease

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The aim of screening program…

• Rational allocation of resources

• Selection of healthy individuals: employment,
military…
• Research; study on natural history of diseases

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Validity of a Test

• Validity of a screening test is measure by its

sensitivity ad specificity.

• The following table summarizes the four possible

relationships between the result of screening test
and the actual presence of disease.

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Validity of a test

Test result Result for gold standard

Total
Disease present Disease absent

Positive a b a+b

Negative c d c+d

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

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Validity of a test

Values are defined as follows:

 a = true-positive results, b = false-positive results,

 c = false-negative results, and d = true-negative

results.

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Validity of a test

1. Sensitivity : is the probability of testing positive if

the disease is truly present and is calculated by
(a/a+c).

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Validity of a test

2. Specificity : is the probability of screening negative if

the disease is truly absent and is calculated by
(d/b+d).

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Example:
Table 1: sensitivity and specificity of breast cancer
screening examination
Breast cancer

cancer confirmed cancer not confirmed Total

Screening test (P/E

and mammography)

Positive 132 983 1115

Negative 45 63,650 63,695

Total 117 64,633 64,810

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1. The sensitivity of mammography plus
physical examination in the above data is:
sensitivity= a/a+c
= 132/177= 74.6%

Interpretation
Of those diagnosed with breast cancer,
approximately 75% tested positive on
screening procedure.

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2. The specificity of mammography plus physical
examination in the above data is:
specificity= d/b+d
= 63,650/64,633= 98.5%

Interpretation
99% of women who did not have the disease
tested negative.

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 Exercise
A new diagnostic test for a certain disease was
evaluated using a group of 100 persons at high
risk for the disease. Sixty of them found to be
positive by the test.
After the 100 people underwent further clinical
evaluation, the disease was confirmed in 50
people, including in 40 who had been found
positive by the test.

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 Exercise …
1. Show these results in the form of 2 by 2 table

2. How many true positive, true negative, false

positive and false negative were there?

3. Calculate the sensitivity and specificity of the

test?

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 Validity of a test

• Sensitivity and specificity are not fixed properties

of a given test.
 Setting the cut off point is arbitrary decision.
 This decision affects the sensitivity and specificity
of the test (tradeoff).
 The decision depends on the purpose for which
the test is to be used, the characteristics of the
disease and its treatment.

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Validity of a test

Validity of a test
• A highly sensitive test is preferable when there
is an important penalty for failing to detect a
disease, when the probability of disease is
relatively low and the purpose of the test is to
discover possible cases.

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Validity of a test

• Specific tests are most useful when the test

result is positive, and are often used to
confirm a diagnosis which has been suggested
by other data.

• A highly specific test is preferable when false

positive results might have negative
consequences.
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 Exercise

• Which test, sensitivity or specificity, should be

maximized in each of the following situations:

1. A test for a disease which is highly fatal in the

absence of treatment, but which can be
treated effectively if detected early.
2. A test for a disease for which the only known
modes of treatment are not very effective and
have many potentially dangerous side-effects.

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3. A test for a disease which is relatively
common and for which the available modes of
treatment do not much affect the outcome

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Validity of a test

Use of multiple tests

• One way of addressing the trade-off between

sensitivity and specificity is to use the result of
several screening tests together.
 Testing in parallel
 Testing in series

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Predictive value of a test

• Predictive value measures whether or not an

individual actually has the disease, given the
results of screening test.

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Predictive value of a test

1. Predictive value Positive (PV+)

• Is the probability that a person actually has
the disease given that he/she tests positive.
• Calculated as: +PV= (a/a+b).

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+PV for breast cancer screening test will be:
+PV = 132/1115= 11.8%.

Interpretation
Of all women who tested positive for the test
11.8% actually did have breast cancer.

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Predictive value of a test

2. Predictive value Negative (-PV)

• Is the probability that an individual is truly
disease free given a negative screening test.
• Calculated as: -PV = d/c+d.

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-PV for breast cancer screening test will be:
-PV= 63,650/63,695 = 99.9%

Interpretation
Of all women who tested negative by the test
99.9% were in fact free of the disease.

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 Predictive value of a test

• The predictive value of a screening test is

determined by the sensitivity and specificity of the
test and the prevalence of the disease in the
population being tested.

• For rare diseases, however the major determinant

of the predictive value positive is the prevalence of
the preclinical disease in the screened population.

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• The following exercises ( exercise-1 and
exercise-2) will help you to see the
interrelationships of sensitivity, specificity, and
prevalence with Predictive value using
hypothetical data.

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 Exercise-1

Disease
Present Absent
Total

Screening test
Positive 900 4950 5850
Negative 100 94,050 94,150
Total 1000 100,000
99,000

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Exercise 1 …
1. Calculate the sensitivity and specificity for
hypothetical data given in exercise 1.

2. Calculate the +PV and –PV of the screening

test.

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 Exercise -2

Disease
Present Absent Total

Screening test
Positive 900 1980 2880
Negative 100 97,020 97,120
Total 1000 99,000 100,000

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Exercise 2 …
1. Calculate the sensitivity and specificity for
hypothetical data given in exercise 2.

2. Calculate the +PV and –PV of the screening

test.

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1. What do you conclude the interrelationships
of sensitivity, specificity with predictive value
of a test based on the finding from exercise 1
and exercise 2?

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effect of Prevalence on the Positive Predictive
Value, with constant Sensitivity and Specificity.
Prevalence (%) Positive Predictive Sensitivity (%) Specificity (%)
Value (%)

0.1 1.80 90 95

1.0 15.4 90 95

5.0 48.6 90 95

50.0 94.7 90 95

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Evaluation of screening programmes
• In considering the cost of screening
programme, two measures are particularly
important.

1. The yield
2. The predictive value of positive test

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1. The yield
• The yield measures the anticipated outcome
in relation to the resource expended.

• The number of cases of disease detected by

the screening test in relation to the total
number of persons screened.

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2. Predictive value of positive test.

• The +PV measures the anticipated outcome

in relation to different source of expenditure.

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 Exercise-1
• A certain screening facility can process 1,000
persons per week, and is attempting the early
detection of a disease with a prevalence of
2%, using a test with a sensitivity of 95% and
specificity of 90%

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Exercise-1
1. Construct the appropriate 2 by 2 table showing
the expected results of the test in relation to
the true disease status?
2. Name and calculate the measure of efficiency?
3. What do you think of the efficiency of the
screening procedure? How could you improve
it while still using the same, unchanged
screening test?

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