Insight from a blind woman
“There is nothing more
pathetic than a man with
eyesight but has no vision.”
Helen Keller
SCREENING
DR ABRAR UMAR
[Link]
ICEBERG PHENOMENA OF DISEASE
Physicians can see the persons with disease who report
to them---tip of the iceberg
The major portion of disease burden hidden as
subclinical, un recognized, undiagnosed cases and carriers
of disease—major portion of iceberg
How to detect the hidden portion of disease?
with the help of screening test!
WHAT IS SCREENING
The search for unrecognized disease or defect by
means of rapidly applied tests examinations or other
procedures in apparently healthy individuals .
(Commission on chronic illness, 1951)
- capable of wide application
-relatively in expensive
-requires little physician ime
AIMS AND OBJECTIVES
To sort out from large group of apparently
1. Those likely to have the disease
2. who are at increased risk of disease
3. To bring apparently normal persons under medical
supervision and treatment
HOPE → early diagnosis and subsequent treatment of
-positives – alters the natural history of disease in a
significant portion
USES OF SCREENING
1- CASE DETECTION OR PRESCRIPTIVE SCREENING
Identification of a unrecognized disease which doesn’t arise
from patients request
2- CONTROL OF DISEASE PROSPECTIVE SCREENING
Like screening of immigrants from infectious disease
such as tuberculosis and syphilis to protect others
3- RESEARCH PURPOSES
Like diseases whose natural history is not fully known e.g.
cancer and [Link] gives basic knowledge
4-EDUCATIONAL OPPURTUNITIES
Creating public awareness
Education of health professionals
TYPES OF SCREENING
Mass screening
High risk or selective screening
Multiphase screening
1-MASS SCREENING
it means screening of whole population or sub group e.g. all
adults
2-HIGH RISK OR SELECTIVE SCREENING
Applied selectively to high risk group
e.g. Cancer of cervix is common in lower social groups
3-MULTI PHASE SCREENING
Application of two or more screening tests in combination
to a large number of people than to carry out separate
screening tests for a single disease.
-health questionnaire
-clinical examinations
-measurements and investigations
Note It has increased the cost of health services
with less benefits
PATHOGENESIS
A B C D
Biologic Disease detectable Symptoms Death
Onset By screening develop
Detectable preclinical phase
LEAD TIME
Detectable preclinical phase in natural history of diseases
LEAD TIME
Interval between detection of disease at screening and when it
would have been detected due to development of signs and
symptoms
EXAMPLES
PPD for tuberculosis
Beck depression inventory for depression
Pap smear for cervical cancer
Mammography for breast cancer
Colonoscopy to detect colorectal cancer
Hearing and vision deficiencies
ELISA for HIV
Anemia , hypertension Rh status, IHD, diabetes, HIV, Hearing
and visual defects, cancer, obesity, tuberculosis, cataract
Screening and Diagnostic tests contrasted
SCREENING TEST DIAGNOSTIC TEST
Done on apparently healthy Done on those with indications or
sick
Applied to groups Applied to single patients, all diseases
are considered
Diagnosis is not final but modified in
Test result are arbitrary and final
light of new evidence, diagnosis is the
Based on one criterion or cut-off sum of all evidence
point (e.g, diabetes)
Based on evaluation of a number of
symptoms, signs and laboratory
Less accurate findings
Less expensive More accurate
Not a basis for treatment More expensive
The initiative comes from the Used as a basis for treatment
investigator or agency providing The initiative comes from a patient
care with a complaint
CRITERIA FOR SCREENING
- Decision to be made
-Ethical scientific and financial justification
Criteria for disease to be screened
Criteria for screening test to be applied
A-WILSON,S CRITERIA FOR DISEASE TO BE
SCREENED
The condition should be an important health problem.
There should be a treatment for the condition.
Facilities for diagnosis and treatment should be available.
There should be a latent stage of the disease.
There should be a test or examination for the condition.
The test should be acceptable to the population.
The natural history of the disease should be adequately
understood.
There should be an agreed policy on who to treat.
The total cost of finding a case should be economically
balanced in relation to medical expenditure as a whole.
Case-finding should be a continuous process, not just a "once
and for all" project.
B-CRITERIA FOR SCREENING TEST TO BE
APPLIED
Acceptability
Repeatability
validity
Safety
Rapidity
Ease of administration
Cost
1-ACCEPTIBILITY
Should be acceptable to the people
2-REPEATABILITY
Test should be repeatable
Must give consistent results on the same subject under
same conditions if repeated more than once
Repeatability depends upon
a. Observer variation
b. Biological variation
c. Error related to technical methods
A- OBSERVER VARIATIONS
1-Intra observer variation
Single observe taking two measurements in the same
subject at the same time with different results
2-Interobserver variation
Variation among different observers taking measurements
on same subject
e.g. interpretation of x- rays, ECG, reading BP
Observational errors can be minimized by
- standardization of procedure
-intensive training
B-BIOLOGICAL VARIATIONS
Biological variability associated with physiological variables
such as blood pressure, blood sugar, serum cholesterol
- changes in parameters observed
- variations in the way patient perceives symptoms and
answers
C-ERRORS RELATED TOTECHNICAL METHODS
Repeatability may be affected by variations inherent in the
method
Defective instruments , faulty reagents ,erroneous
calibration
Test itself may not be reliable or inappropriate
3-VALIDITY
The ability of a test to separate or distinguish those who
have disease from those who do not have
Accuracy refers to the closeness with which measured
values agreed with the true values
COMPONENTS OF VALIDITY
1- Sensitivity
2- Specificity
1-SENSITIVITY
The ability of test to identify correctly all those who have
the disease that is true positive
90% sensitivity means that 90% of the diseased people
screened by the test will give true positive ,remaining 10%
will be false negative
2-SPECIFICITY
The ability of a test to identify correctly all those who
donor have the disease that is true negative
90% specificity means that 90% of not diseased persons
will give true negative results,remaining10%
will be false positive
Screening Test
2x2 table
Actual disease
status
Positiv Negativ
(Gold Standard)
Total
Result of e e
Screening test
True positive False positive a+b
Positiv a b
e
Negativ False negative True negative c+d
e c d
Total a+b+c+d
a+c b+d
Screening Test
a= The number of individuals for whom the screening test is
positive and they actually have the disease (True positives)
b= The number of individuals for whom the screening test is
positive but they do not have the disease (False positives)
c= The number of individuals for whom the screening test is
negative but they actually have the disease (False negatives)
d= The number of individuals for whom the screening test is
negative and they actually do not have the disease (True
negatives)
Screening Test
So, interpreting the cells
a+c = All those who actually have the disease.
b+d = All those who actually do not have the
disease.
a+b = All those who test positive on the
screening test.
c+d = All those who test negative on the
screening test.
Screening Test
Sensitivity = a/(a+c)x100 (%)
Specificity = d/(b+d)x100 (%)
Positive predictive value= a/(a+b)x100 (%)
Negative predictive value= d/(c+d)x100 (%)
Prevalence = a+c / n x 100 (%)
Accuracy = a+d / n x 100 (%)
PREDICTIVE ACCURACY
Performance of a test is measured by predictive value
---diagnostic power of the test
a. POSITIVE PREDICTIVE VALUE- PPV
PPV of a test is probability that the individual who test
positive for a disease actually have the disease
e.g. If 100 test positive for HBV and only 80 are true
positive then test has PPV=80%
b. NEGATIVE PREDICTIVE VALUE- NPV
NPV is probability that individuals who test negative for a
disease are really disease free
e.g. If HIV test100 negative for HIV and only 80 are true
negative ,then NPV is 80%
YIELD
Its amount of previously unrecognized disease that is found
as a result of screening effort it depends upon
Sensitivity of test
Specificity of test
Prevalence of disease
Participation of individuals
-by limiting diabetic screening to persons over 40 years
yield of screening test increased
-high risk populations selected for increasing yield
-two are more tests to enhance the specificity or sensitivity
of screening test
Exercise
A researcher has developed a screening test for a
certain type of cancer. She has found that of the 2440
individuals screened, 50 actually had the disease. Of
the 56 patients found to be positive on the screening
test 44 actually had the disease.
Set up a 2 X 2 table
Calculate the measures of validity and yield of the
test
Interpret your results in words.
Solution
Cance Total
r
Yes No
44 12 56
Positive
Negative 6 2378 2384
50 2390 2440
Results
Sensitivity = a / a+c = 44/50 =0.88 or 88%
Specificity = d /b+d =2378/2390= 0.99 or 99%
Positive predictive value=a/a+b=44/56=0.78 or 78%
Negative predictive value= d/c+d=2378/2384=99%
Results
The ability to detect true positives is 88 %
The ability to detect true negatives is 99%
The test is able to predict that 78% of persons with a
positive test will have the disease and 99% of persons
with a negative test will not have the disease.