Screening

• Definition:
The presumptive identification of
unrecognized disease or defect by the
application of tests, exams or other
procedures which can be applied rapidly to
sort out apparently well persons who
probably have a disease from those who
probably do not”
• Screening:

• Aims to detect early disease before it

becomes symptomatic .
• Early detection early treatment
better prognosis
NATURAL HISTORY OF DISEASE:

• Refers to the progression of a disease

process in an individual over time in the
absence of treatment, from the moment of
exposure to causal agents until the
disease process ends either in:
 recovery,
 chronicity or
 death.
NATURAL HISTORY OF DISEASE:
• After the disease process has been
triggered, pathological changes then occur
without the individual being aware of them.
• This stage of subclinical disease, extending
from the time of exposure to onset of
disease symptoms, is usually called the
incubation period for infectious diseases,
and the latency period for chronic diseases.
• During this stage, disease is said to be
asymptomatic (no symptoms) or unapparent.
NATURAL HISTORY OF DISEASE:
• The onset of symptoms marks the
transition from subclinical to clinical
disease.
• Most diagnoses are made during the
stage of clinical disease.
NATURAL HISTORY OF DISEASE:
DISEASE SPECTRUM:

Pre-symptomatic Unrecognized recognized

disease symptomatic symptomatic
disease disease
ICEBERG PHENOMENA

The clinically apparent cases represent only

a small fraction of the total cases of
disease in the community and reprsented
by the tip of the iceberg. Inapparent
cases, including preclinical, subclinical,
chronic, and latent diseases being even
more prevalent, represented by the huge
submerge portion of the iceberg.
SCREENING:

• Aims to detect early disease before it

becomes symptomatic.
• Early detection of disease leads to a more
favorable prognosis due to early
treatment, as compared to delayed
treatment.
• Is an important aspect of prevention, 2ry.
• Left, untreated pre-clinical disease,
typically progresses to clinically-evident
disease.
SCREENING:

SCREENING:
• Examples for screening tests :
Examples of screening along the spectrum
Risk factors:
• Hypercholesterolemia, hypertension
Pre symptomatic:
• Congenital hypothyroidism, DM, HIV
Unrecognized symptomatic disease:
• DM, Vision and hearing problems in young
children, iron deficiency anemia, depression
• Prostate cancer, breast carcinoma in situ
Screening is done through Screening Tests
(  tests applied to individuals without observed signs of
disease).
>>And if the individual had a +ve result he then may take a
Diagnostic Test 
(A test used on individuals with clinical signs or other clinical
information consistent with the presence of the condition)..

so:

screening ≠ diagnosis
DIAGNOSTIC VS. SCREENING:

• Diagnostic Test: A test used on

individuals with clinical signs or other
clinical information consistent with the
presence of the condition.

• Screening Test: A test applied to

individuals without observed signs of
disease.
SCREENING PROCESS
Asymptomatic Population
Screening

Test negative Test positive

Unlikely to have the disease Likely to have the disease

Diagnosis
(confirmation)
Unaffected Affected

Re-screen Intervene
(Treatment)
CRITERIA FOR A SUCCESSFUL
SCREENING PROGRAM
For screening to be successful you need a:
– Suitable disease
– Suitable test
– Suitable screening program
CRITERIA FOR A SUCCESSFUL
SCREENING PROGRAM: DISEASE
 Present in the screened population.
 prevalence of pre-clinical stage of the disease
should be relatively high among those
screened.
 High morbidity or mortality (serious): must be an
important public health problem.
CRITERIA FOR A SUCCESSFUL
SCREENING PROGRAM: DISEASE
 Pre-clinical disease left untreated typically
progresses to clinically-evident disease (e.g. no
spontaneous regression).
 Early detection of disease leads to a more
favorable prognosis due to early treatment, as
compared to delayed treatment.
 The natural history of the disease should be
understood, such that the detectable sub-
clinical disease stage is known and identifiable.
CRITERIA FOR A SUCCESSFUL
SCREENING PROGRAM: TEST

 Should be relatively sensitive and specific.

 Should be simple and inexpensive.
 Not invasive and impose the least
discomfort
 Should be very safe.
 Must be acceptable to subjects and
providers.
CRITERIA FOR A SUCCESSFUL
SCREENING PROGRAM
Have an Exit Strategy
Facilities for diagnosis and appropriate
treatments should be available for individuals
who screen positive.

It is unethical to offer screening when no

services are available for subsequent
treatment.
• CRITERIA FOR SCREENING:
we need a:
– Disease
– Test
– Policy

with certain characteristics .

• CRITERIA FOR SCREENING:

the DISEASE should be :

 Medically important.
 Clearly defined.
 Prevelance reasonably well-known.
 Natural history known.
 Effective prevention & effective control.
• CRITERIA FOR SCREENING :

the TEST should be :

Simple
Safe
Reasonable
With defined cut off level
Valid: able to differentiate between those who is
likely to have the disease and who is unlikely to
have the disease .
Reliable : gives the same results when repeated
• CRITERIA FOR SCREENING :

the Policy should have :

*Cost effective program.

*Available facilities for diagnosis and
treatment .
*Acceptance of the participants to the
course of the procedure after a +ve result.
• The validity of a screening test :

o The assessment of a screening test

effectiveness .

Contains 4 indices :
o Sensitivity
o Specificity
o Positive predictive value
o Negative predictive value
• EVALUATING SCREENING TESTS:

Validity is analogous to accuracy

=
How good is the screening test compared with
the confirmatory diagnostic test?
• SENSITIVITY:

The ability of the test to identify correctly

those who have the disease (a) from all
individuals with the disease (a+c)

 Proportion of individuals who have the

disease who test positive by screening test
(true positive rate)
SENSITIVITY:

True Disease
yes no Sensitivity
+ a b
ScreeningTest

=
a+b

- c d c+d
a
a+c b+d a+c
• SPECIFICITY :

The ability of the test to identify correctly

those who do not have the disease (d) from
all individuals free from the disease (b+d)

 Proportion of individuals who don’t have the

disease who test negative (true negative
rate)
• SPECIFICITY:

True Disease
yes no Specificity
a b
=
Screening Test

+ a+b

- c d c+d d
a+c b+d
b+d
• VALIDITY OF SCREENING TEST - example :
Breast Cancer(confirmed)
+ -

Physical Exam +
132 983
and Mammo-
graphy
- 45 63650

Sensitivity = a / (a + c)
= 132 / (132 + 45) = 74.6%

Specificity = d / (b + d)
= 63650 / (983 + 63650) = 98.5%
 • VALIDITY OF SCREENING TEST -
example:

That means:

• Sensitivity: Screening by physical exam and

mammography will identify 75% of all true breast cancer
cases.

• Specificity: Screening by physical exam and

mammography will correctly classify 98.5% of all non-
breast cancer patients as being disease free.
 Disease
Present Absent

True False
positives positives
Screening

Positive
Test

False True
negatives negatives
Negative
• Validity : Predective values

True Disease Status

(Confirmatory/Gold standard test)
Present Absent
a b
Screening

Positive a+b

Negative c d c+d
Test

a+c b+d N
 • POSITIVE PREDICTIVE VALUE /
P.P.V.
the proportion of correctly identified cases among
test results .
True Disease a
yes no
=
Screening

P.P.V.
a+b
+ a b a+b
Test

- c d c+d

a+c b+d N
 • NEGATIVE PREDICTIVE VALUE /
N.P.V.
the proportion of correctly excluded of non-
diseased individuls among the -ve results .
True Disease
yes no
Screening

d
+ a
c
b
d
a+b N.P.V.
= c+d
Test

- c+d

a+c b+d N
Ex.: a test is used in 50 people with disease and 50 people without. The results :

True Disease Status

(Confirmatory/Gold standard test)

Present Absent
Screening
Positive
48 3 51
Test

Negative 2 47 49

50 50 100
Sensitivity = 48/50 x 100 = 96%
Specificity = 47/50 x 100 = 94%
Positive Predictive Value = 48/51 x 100 = 94.1%
Negative Predictive Value = 47/49 x 100 = 95.9%
 • INTERPRETATION OF PREDICTIVE
VALUE:
PPV: a / (a + b) = 94.1%
Among persons who screen positive, 94.1% are
found to have the disease.
True Disease
Screening

yes no
+ a b a+b
Test

- c d c+d
a+c b+d N
NPV: d / (c + d) = 95.9%
Among persons who screen negative, 95.9% are
found to be disease free. 39
RELIABILITY OF SCREENING TEST

 The extent to which the screening test will

produce the same or very similar results each
time it is administered, on the same individuals
under the same conditions.
 A test must be reliable before it can be valid.
 Unreliable test will misclassify the screenees
RELIABILITY OF SCREENING TEST
• TYPES of screening :

  Screening for disease detection is

categorized into :
1) Mass screening : aims large population
groups that vary widely in their risk of the
disease.
2) Selective screening : applied only to groups
at high risk .
• TYPES:

3) Multiphase screening: employs multiple

screening tests at the same time.

4) Case finding; opportunistic screening:

occurs in a clinical setting when patients visit
their physician (or other health provider) for
general consultation or unrelated problems, and
physician takes the opportunity to request one
or more routine screening tests.
Screening is not
always free of risk
Risks of Screening

• False Positives
– anxiety
– fear of future tests
– monetary expense
Risks of Screening

• False Negatives
– delayed intervention
– disregard of early signs or
symptoms which may lead to
delayed diagnosis
Exercise 1-A breast cancer screening
examination for women showed the following
results:
Breast Cancer
+ -

+ 400 995
Results of
mammography
- 100 98905
Exercise 2

A new screening for a certain disease was

administered to 480
persons, 60 of whom are known to have the
disease. The test
was positive in 50 of the persons with the
disease as well as in
20 persons without the disease. Evaluate
the screening test by all measures:
.
Calculate the sensitivity,
specificity +ve and –ve
predictive values as well
and interpret your results
THANK YOU