Screening

BY Fisaha Haile
 Outline
• Definition

• The Screening pathway

• Accuracy of screening tests

• Criteria for population based screening

• Organizational screening programs

• Screening Ethics
 What is screening?
It is the early detection
– of disease,

– precursors to disease, or

– susceptibility to disease

in individuals who do not show any signs of the

disease
 Diagnostic and Screening tests

• Diagnostic and screening tests are useful for a

decision to initiate or continue a therapeutic
(preventive) intervention.

Screening tests
• are tests done in individuals with no such
symptoms or sign.

Diagnostic tests
• are tests performed in persons with a
symptom or a sign of an illness.
Diagnostic and screening tests
May be based on
– Standardized interviews,

– Physical examinations,

– Laboratory tests,

– More sophisticated measurements

• radiography,
• electro-cardiograph,
• slit-lamp examination.
 The Screening pathway
Healthy

Disease or
precursor detectable Screening possible

Symptoms develop Intervention to avert

Disease development or
its consciences
Advance disease
Life prolonged
Death
There are different types of screening, each
with specific aims;
1. Mass screening:
It involves the screening of a whole population.

2. Multiple or multi-phase screening:

It involves the use of a variety of screening
tests on the same occasion.

3. Case finding or opportunistic screening;

It is restricted to patients who consult a health
practitioner for some other purposes.
 Accuracy of screening tests
• Sensitivity

• Specificity

• Predictive Value Positive (PV+)

• Predictive Value Negative (PV-)

• Percentage of Correct Classification

 Validity

• Sensitivity
– Probability to test positive among truly affected

• Specificity
– Probability to test negative among truly unaffected
people

• It is desirable to have a screening program that

is both highly sensitive and highly specific.
 Performance
• Predictive value positive
– Probability of being affected among test positives

• Predictive value negative

– Probability of being unaffected among test negatives

• Percentage of Correct Classification

– ability of the screening program to correctly classify
individuals either affected or unaffected
 Screening tests

Disease Disease
present absent

Test Positive a b a+b

Test Negative c d c+d

a+c b+d N
Screening tests
From this table, the following values are
commonly calculated:
Cont…
Relationship between Prevalence and
predictive values
(Predictive value Positive is
directly related to the PV (+)
prevalence of a disease
in a community.
Prevalence
• Predictive value Negative
is inversely related to the
prevalence of a disease
in a community. PV (-)

Prevalence

when the sensitivity and specificity are constant

 Percentage of correct classification

• ability of the screening program to correctly

classify individuals either affected or unaffected

TP + TN a+d
TP + FN + TN + FP
or a+c+d+b

Correctly diagnosed

Total tested
 Screening characteristics

Disease Disease
present absent

Test Positive 95 45 140

Test Negative 5 855

860

100 900 1000

 What does it mean?

• The sensitivity is 95% (95/ 100)

– Of a 100 people that have the disease, 95
tested positive

• The specificity is 95%. (855/ 900)

– Of a 900 people that have no disease, 855
tested Negative
 Cont

• The positive predictive value is 67.9% (95/ 140).

– Of a 140 people that test positive, 95 will truly have
disease.
• The negative predictive value is 95% (855/ 860).
– Of a 860 people that test Negative, 99.4% will truly
have no disease
 Criteria for population based screening

1. Knowledge of disease

2. Feasibility of screening procedures

3. Diagnostic and treatment

4. Cost consideration
 1. Knowledge of disease
• The condition must be an important problem
(severity, prevalence)

• There should be a recognizable latent or early

symptomatic stage
(pre-clinical recognition)

• The natural history of the condition, including

development from latent to declared disease, should
be adequately understood
 Natural History of diseases

Usual Time
Of diagnosis

Exposure Pathologic Onset of

changes symptoms

Stage of Stage of Stage of Stage of recovery,

Susceptibility sub-clinical disease Clinical disease disability or death

Time of
Screening
 2. Feasibility of screening procedures

• There should be a suitable test or examination

(High sensitivity and specificity)

• The test should be acceptable to the population

(Taking saliva test vs taking occult blood from
rectum ‘colorectal test’)

• Case-finding should be a continuing process and

not a “once and for all” project
(occurrence of disease is continuous)
 3. Diagnostic and treatment
• There should be an accepted treatment for patients
with recognized disease
(need of treatment that alters the occurrence of disease)

• Facilities for diagnosis and treatment should be

available
(Continuation of follow up tests and Rx is necessary)

• There should be an agreed –upon policy

concerning whom to treat as patients
 4. Cost consideration

• Cost (diagnosis and treatment of patients diagnosed)

(cost effectiveness of the program)

• The cost should be economically balanced to

possible expenditure on medical care as whole
(though difficult to measure, they are usually
cost effective)
 Organizational screening programs
• Public and provider education
(Public mobilization about the screening)

• Population based recruitment and recall system

• Follow-up of screening results

• Adequate resources

• Quality assurance for all components

• Outcome evaluation
 Screening Ethics
• Informed consent for testing and follow-up
(The risks and benefits of the tests, including
the consequences of testing should be
provided)

• Considerations of risks of screening

(false positive and false negative)

• Distributive justice
 Screening in developing countries

• Development of advanced screening tests require

special consideration in planning

• Local circumstances must be considered

• It is unethical to offer screening without adequate

follow-up care