Dasar Epidemiologi :
SCREENING
(Skrining)
dr. M Sakundarno Adi, MSc.,PhD.
Fakultas Kesehatan Masyarakat Universitas Diponegoro
Semarang
Outline :
1. Remember: Natural history of disease?
2. Definition (screening/ test )?
3. Principle of Screening (validity of screening test)?
4. Interpretation of screening test results?
5. exercise
SCREENING ?
SCREENING TEST?
DIAGNOSTIC / TEST?
SCREENING:
⚫ The early detection of disease, precursors of disease,
susceptibility to disease in individuals who do not show
any signs of disease.
⚫ Is the application of a relatively simple, inexpensive test,
examinations or other procedures to people who are
asymptomatic, for the purpose of classifying them with
respect to their likelihood of having a particular
disease,
⚫ a means of identifying persons at increased risk for
the presence of disease, who warrant further evaluation.
DIAGNOSIS ~ DIAGNOSTIC:
⚫ Diagnosis involves confirmation of presence or
absence of disease in someone suspected of or at risk
for disease
⚫ Diagnostic is process to identify a condition or its cause.
⚫ A diagnostic test is a test used to identify a condition or
its cause. It is used to diagnose.
NATURAL HISTORY OF DISEASE
Cured
Carrier
Chronic
Death
Agent starts permanent change Signs/ symtomps start to begin
entering starts appear status change
Period of incubation period Early and intermediate phase Terminal phase
Pre-patogenesa
Tahap Pre-simtomatik Tahap simtomatik
Natural History of Disease
Detectable subclinical disease
Susceptible Subclinical Clinical Stage of Recovery,
Host Disease Disease Disability, or Death
Diagnosis
Point of sought
Exposure
Onset of
symptoms
Screening
Screening Process
Population
(or target group)
Screening
Test Test
Negative Positive Clinical
Exam
Unaffected Affected
Re-screen Intervene
SCREENING: …..
⚫ Aims of screening are to reduce morbidity and mortality
from disease among persons being screened.
⚫ Screening-test is a test used to detect disease at the
early phase, precursors of disease, susceptibility to
disease in individuals who do not show any signs of
disease.
⚫ Forms of screening-test:
Questions, Clinical Examinations, Laboratory Tests,
Genetic Tests, X-rays, etc
SCREENING: …..
Screening-test
⚫ should be relatively sensitive and specific
⚫ should be simple and inexpensive
⚫ should be very safe
⚫ must be acceptable to subjects and providers
VALIDITY OF SCREENING-TEST
Key measures:
1. Sensitivity (Se)
2. Specificity (Sp)
3. Positive Predictive Value (PPV)
4. Negative Predictive Value (NPV)
VALIDITY OF SCREENING-TEST …..
⚫ Validity is analogous to accuracy
⚫ The validity of a screening test is how well the given
screening test reflects another test of known greater
accuracy
⚫ Validity assumes that there is a gold standard to which
a test can be compared
Disease
Present Absent
Screening
Positive a b a+b
Test
Negative c d c+d
a+c b+d N
Disease
Present Absent
True False
Screening
Positive positives positives
Test
False True
negatives negatives
Negative
Sensitivity
⚫ Proportion of individuals with the disease who
have the test positive (~ true positive rate)
→ tells us how well the test show “+” among
individuals with the disease
Disease
yes no a
Screening
+ a b a+b Sensitivity =a + c
Test
- c d c+d
a + cb + d N
Specificity
⚫ Proportion of individuals with no disease who
have the test negative (~ true negative rate)
→ tell us how well the test show “-” among
individuals with no disease
Disease
yes no d
Screening
+ a b a+b
Specificity =b + d
Test
- c d c+d
a + cb + d N
Predictive Value
⚫ Measures whether or not an individual actually
has the disease, given the results of a screening
test
⚫ Affected by
⚫ specificity
⚫ prevalence of preclinical disease
⚫ Sensitivity
a+c
Prevalence =
a+b+c+d
Disease
Present Absent
Screening
Positive a b a+b
Test
Negative c d c+d
a+c b+d N
Positive Predictive Value
⚫ Proportion of individuals with test positive who
actually have the disease
→ tells us how well a “+” test picks up disease
Disease
yes no
a
Screening
+ a b a+b P.P.V. =a + b
Test
- c d c+d
a+c b+d N
Negative Predictive Value
⚫ Proportion of individuals with test negative who
don’t have the disease
→ tell us how well a “-” test detects no disease
Disease
yes no d
Screening
+ a b a+b N.P.V. =c + d
Test
- c d c+d
a + cb + d N
Negative Predictive Value
⚫ Proportion of individuals with test negative who
don’t have the disease
→ tell us how well a “-” test detects no disease
Disease
yes no d
Screening
+ a b a+b N.P.V. =c + d
Test
- c d c+d
a + cb + d N
A test is used in 50 people with disease and
50 people without. These are the results.
Disease
Present Absent
48 3 51
Screening
Positive
Test
Negative 2 47 49
50 50 100
Hitung :
⚫ Se
⚫ Sp
⚫ PPV
⚫ NPV
Disease
Present Absent
48 3 51
Screening
Test Positive
Negative 2 47 49
50 50 100
Sensitivity = 48/50 = 96 %
Specificity = 47/50 = 94 %
Positive Predictive Value = 48/51 = 94.1 %
Negative Predictive Value = 47/49 = 95.9 %
Criteria for a Successful
Screening Program
⚫ Disease
- present in population screened
- high morbidity or mortality; must be an important
public health problem
- early detection and intervention must improve
outcome
- 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
⚫ Screening Test
- should be relatively sensitive and specific
- should be simple and inexpensive
- 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
Screening is not
always free of risk
In population screened….
False positives tend to swamp true
positives in populations, because most
diseases we test for are rare
Risks of Screening
⚫ True Positives
⚫ “labeling effect” (classified as diseased from the time
of the test forward)
⚫ False Positives
⚫ confusing
⚫ 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
Sources of Bias in the Evaluation of
Screening Programs
⚫ Lead time bias
⚫ Length bias
⚫ Volunteer bias
Exercise (individual/ group):
Explain and give the example for :
1. Lead-time bias
2. Length bias
3. Volunteer bias
TERIMA KASIH
M.S. Adi,MD,MSc.,PhD 34
M.S. Adi,MD,MSc.,PhD 35
M.S. Adi,MD,MSc.,PhD 36
M.S. Adi,MD,MSc.,PhD 37