SCREENING

PRESENTER:

DR. SHAILAJA DARAL

MODERATOR: DR. ANITA VERMA

ASSO. PROFESSOR
DEPT. OF COMMUNITY MEDICINE
VMMC AND SAFDARJUNG HOSPITAL

DEFINITION OF SCREENING
The search for unrecognized disease or defect by means of
rapidly applied tests, examinations or other procedures in
apparently healthy individuals.*
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.*
Tests done in individuals with no symptom or sign of an illness are
referred to as screening tests.*
(* K. Park Textbook of PSM 21st edition;
* J M Last Dictionary of Epidemiology 4th edition, WHO Public Health
Papers 1968;
* J H Abramson and Z H Abramson Survey methods in Community
Medicine 5th edition)

BASIS OF SCREENING
Iceberg phenomenon
of disease
tip of the iceberg
CLINICAL DISEASE
submerged portion
HIDDEN
BURDEN
DISEASE

OF

BASIS OF SCREENING

LEAD TIME

BASIS OF SCREENING
Screening is a form of secondary prevention.
It detects disease in its early asymptomatic phase
whereby early treatment can be given and disease
can be cured or its progression can be delayed.
It has both
components.

diagnostic

(?)

and

therapeutic

SCREENING TEST VERSUS DIAGNOSTIC TEST

Screening test
1. Done on apparently
healthy individuals
2. Applied to groups
3. Results are arbitrary
and final
4. Based on one criteria
and cut-of
5. Less accurate
6. Less expensive
7. Not
a
basis
for
treatment
8. Initiative comes from
investigator

Diagnostic test
1. Done on sick or ill
individuals
2. Applied
on
single
patient
3. Diagnosis is not final
4. Based on evaluation of
a no. of signs/symptoms
& lab findings
5. More accurate
6. More expensive
7. Used as a basis for
treatment
8. Initiative comes from a
patient

COMMON SCREENING TESTS

FASTING BLOOD GLUCOSE FOR DIABETES

BLOOD PRESSURE FOR HYPERTENSION
PSA TEST FOR PROSTATE CANCER
PAP SMEAR FOR CERVICAL CANCER
MAMMOGRAPHY FOR BREAST CANCER
FECAL OCCULT BLOOD FOR COLON CANCER

TYPES OF SCREENING
1. MASS SCREENING
Application of screening test to large, unselected
population. Everyone in the group is screened
regardless of the probability of having the disease
or condition.
Example: a) visual defects in school children
b) mammography in women aged 40 years or
less
c) newborn screening program in Japan

2. HIGH RISK / SELECTIVE / TARGETED SCREENING

The screening of selected high-risk groups in the
population.
Example: a) screening fetus for Downs syndrome
in a
mother who already has a baby with
Downs
syndrome
b) screening for familial cancers, HTN and DM
c) screening for CA Cervix in low SES women
d) screening for HIV in risk groups

3. MULTIPURPOSE SCREENING
The screening of a population by more than one test
done simultaneously to detect more than one disease
Example: a) screening of pregnant women for VDRL,
HIV,
HBV by serological tests
4. MULTIPHASIC SCREENING
The screening in which various diagnostic procedures
are employed during the same screening program.
Example: a) DM FBS, Glucose tolerance test
b) Sickle cell anemia CBC, Hb electrophoresis

5. OPPORTUNISTIC / CASE FINDING SCREENING

There is no accurate or precise diagnostic test for
the disease and where the frequency of its
occurrence in the population is small. The main
objective is to detect disease and bring patients to
treatment.
Example:

a) RHD in children

USES OF SCREENING
1. CASE DETECTION prescriptive screening, people are
screened for their own benefit
(cancer, diabetes, hypertension)
2. CONTROL OF DISEASE prospective screening, people
are screened for the benefit of others
(HIV, STI)
3. RESEARCH to know the natural history of a disease
4. EDUCATION public awareness

CRITERIA FOR CHOOSING A SCREENING TEST

1. DISEASE
a) Significant burden of disease
b) Detectable and long preclinical stage of disease
c) Adequately understood natural history of disease
d) Appropriate test available for early detection of
disease
e) Facilities for diagnosis of disease
f) Early detection of disease has outcome benefit
g) Efective treatment available for disease
h) Policy of screening program for disease

2. SCREENING TEST
a) Inexpensive
b) Acceptable
c) Valid
d) Reliable
e) Yielding

GOLD STANDARD
GOLD STANDARD: an external source of truth
regarding the disease status of each individual in
the population. Gold standard is a benchmark and
its results are considered definitive.
Infections CULTURE
Cancers BIOPSY
Drug testing RANDOMIZED CONTROLLED TRIAL
Cause of death AUTOPSY

WHAT IS VALID AND RELIABLE?

VALIDITY IS THE ACCURACY OF A TEST.

RELIABILITY IS THE PRECISION OF A TEST.
ACCURACY: how close is result of a test to its true
value?
PRECISION: how close are the results of a test on
repetition?

GOLD STANDARD AND SCREENING TEST

VALIDITY
An expression of the degree to which a test measures what it
purports to measure.
How to understand validity?
ESTIMATE: a measurement or statement about the value of a
quantity under study.
An epidemiological estimate is the end product of the study
design, the study conduct and the data analysis.
Error is a false or mistaken result obtained in a study or
experiment.
Systematic error is one sided variation of measurements from
the true value. It has a recognizable source.
A study that has little systematic error is described as
VALID.

COMPONENTS OF VALIDITY

Ds present
Test positive

Test negative

Ds absent

SENSITIVITY
The ability of a test to correctly identify those who
have the disease. TP
a/ (a + c) expressed as percentage.
Problem of FP.
Ds present
Test positive

Test negative

Ds absent

SPECIFICITY
The ability of a test to correctly identify those who
do not have the disease. TN
d/ (b + d) expressed as percentage.
Problem of FN.
Ds present
Test positive

Test negative

Ds absent

ACCURACY
ACCURACY = TP + TN / TP + FP + TN + FN

ACCURACY = (SENSITIVITY) X (PREVALENCE)

+
(SPECIFICITY) X (1 - PREVALENCE)

PROBLEM OF FN AND FP
FN: false reassurance
ignoring of disease signs and symptoms
postponement of treatment
detrimental to overall health
FP: further testing
discomfort, inconvenience, anxiety
burden on health facilities
emotional trauma
difficulty in de-labeling

CHANGING CUT-OFF POINTS:

SENSITIVTY AND SPECIFICITY OF IMPORTANT

TESTS
1. Mammography: Sensitivity 75 95%
Specificity 83 98%
2. PAP test: Sensitivity 29 56%
Specificity 94 100%
3. PSA test (4 ng/ml): Sensitivity 20 32%
Specificity 94 97%
4. FBS (5mmol/L):Sensitivity 85 89%
Specificity 70 77%
5. RAPID ELISA: Sensitivity 99.5%
Specificity 98%

USE OF MULTIPLE TESTS

Sequential Testing (Two-Stage Screening)

After the first (screening) test is conducted, those
who tested positive are brought back for the second
test to further reduce false positives.
Consequently, the overall process will increase
specificity but with reduced sensitivity.