CHAPTER
6
SCREENING
1. Concept of Lead Time
2. Criteria for Screening
3. Evaluation of Screening Test
Screening 75
Screening is defined as the search for unrecognised disease or defect by means of rapidly applied tests, examinations or
other procedures in apparently healthy individuals.
Screening should be done only for those diseases where there is considerable time lag between disease onset and the usual
time of diagnosis.
Between the onset of the disease and the usual time of diagnosis there are several critical points which determine the
severity of the disease and flre success of treatment in reversing the disease process. These critical points are depicted
below.
Disease First possible Final critical Usual time of Outcome
onset point of diagnosis diagnosis diagnosis of disease
A B C D
Screening time
Lead Time
Lead time is the advantage gained as a result of screening. A screening test will detect the disease between the time period
B and C, whereas the usual time of diagnosis is at period D. Thus be screening there is a gain in time period between B and
D which is called as "LEAD TIME".
Definition
o Screening is defined as search made for detecting the hidden disease among apparently healthy individuals in
commr:nity, by rapidly applying a test which is called as screening test.
Criteria for Screening
The criteria for screening are based on two considerations
o Disease
r Test
Criteria for Disease to be Screened
e It should be of public health importance.
o It should have recognisable early stage.
o The natural history of the disease or condition should be known.
o It should have a test by which disease can be diagnosed before the onset of signs and sl,rnptoms.
o There must be facilities available to confirm the diagnosis.
o There should be guidelines as to who is to be considered as patients i.e. cut-off levels or findings that are suggestive of
disease status should be defined.
o There must be effective treatrnent.
o Early detection and treatment should reduce morbidity and mortality.
o The benefits of early detecbion should exceed the risks and costs.
Criteria for Screening Test
It should fuIfilIthe criteria of
o Acceptability
o Repeatability
o Validity
76 Short Notes in Community Medicine
It should be simple, safe, cheap and easy to administer
1) Acceptability
o It shouldbe acceptable for people so thatthey canco-operate. If test is painful, embarrassing and causes discomfort,
people will not co-operate. e.g. injections, per-rectaVper vaginal examination etc.
2) Repeatability
o It should be reliable or repeatable or reproducible i.e. when the test is repeated in same individuals under same
conditions it should give consistent results.
o Repeatability of the test depends on three factors i.e.
a) Obseraer oariation
0 Lrtra-Observer Variation: It is the variation observed in test result when same observer applies the test on
same individual at same time under identical conditions.
- e.g. recording different results of peripheral smear by same observer on same slide on two different days.
It can be overcomed by training.
ii) Inter-Observer Variation: It is the variation observed in test result when two or more observer applies the
same test on one individual under identical conditions.
- e.g. if one lab tedrnician find the tubercle bacilli in sputum smear while other finds it normal.
It can be overcomed by standardisation of procedure and intensive training.
b) Biological or subject oariation
It is the variation observed in test result in same individual under identical conditions.
- e.g. variation in pulse rate or respiratory rate at moming or evening; variations in the answer givenby subject
due to difficulty in recollection of past events or gives socially culturally acceptable answers.
c) Errors due to technical methods
It is the variation observed in test result due to defect in machine or procedure, callibration not done correctly,
faulty reagents or the test itself maybe inappropriate orunreliable. It canbe overcomeby calibration of equipments.
3) Validity
o Validity me€u:rs ability of test to correctly identify those with disease and those without the disease.
. e.g. oral glucose tolerance test is more valid than urine for sugar.
o Validity has two components:
Sensitivity (True positive rate): It is ability of test to correctly identify those with disease.
Specificity (True negative rate): It is ability of test to correctly identify those not having disease.
Definition of Screening
Screening is defined as the search for unrecognised disease or defect by means of rapidly applied tests, examinations or
other procedures in apparently healthy individuals.
Measures for evaluating a screening test
1) Sensitivity
2) Specificity
3) Predictive value of a positive test
4) Predictive value of a negative test
5) Percentage of false positives
6) Percentage of false negatives
Screening Test Result Diseased Non-Diseased Total
Positive a (True positive) b (False positive) a+b
Negative c (False negative) d (True negative) c+d
Total a+c b+d a+b+c+d
Screening 77
Sensitivity (Irue positive rate): It is ability of test to correctly identify those with disease that is the percentage of
diseased persons showing positive test result.
Formula:Sensitivity= a
- a+c
x100
e.g. Sensitivity of.90o/o, means of diseased persons are correctly identified as "true positive"/having the disease
90o/o
and remaining 10"/" are incorrectly labelled as not having disease as the test is negative (false negative).
Specificity (True negative rate): It is ability of test to correctly identify those not having disease that is percentage of
non-diseased persons showing test result negative.
Formula : Specificity
' = --1-
b+d
* 1gg
e.g. Specificity of 90o/o, means 90"/o of persons without the disease are correctly identified as "true negative" i.e. not
having the disease and remainingl0Y" are incorrectly labelled as having disease as the test is positive (false positive).
Predictive value of a positive test Predictive value reflects the diagnostic power of the test. The predictive accuracy
depends on sensitivity, specificity and prevalence of disease.
Formula : Predictive value of a positive 1gs1= ---1- 1 166
a+b
The predictive value of a positive test reflects the probability of the person with a positive test result actually having
the disease.
The predicitve value of the test decreases with dedine in prevalence of the disease.
Predictive value of a negative test The predictive value of a negative test reflects the probability of the person with a
negative test result NOT having the disease.
Formula : Predictive value of a negative 1"s1 = d, x 100
c+d
a False Positive: means a test result shows positive even though the person is not having the disease.
Formula : False positive = --!-
b+d
* 1gg
If the test results are false positive, the person may be unduly subjected to a series of diagnostic tests to confirm the
diagnosis. If a test has high specificity, there are very few false positives.
o False Negative: means a test result shows negative even though the person is actually having the disease.
Formula : Falsenegative:
c x 100
a+c
If the testresults are falsenegative, the personmayignore developmentof signs and symptoms and postpone treatment.
If a test has high sensitivity, there are very few false negatives.
Varied prevalence of disease in population does not affect the sensitivity and specificity of test while it affects the predictive
value of test. From epidemiologist perspective the sensitivity *d
specificity is important while from clinician perspective
the predictive value is important.
78 Short Notes in Community Medicine