MODULE 07: SCREENING IN
DISEASE CONTROL
February 9, 2025 EPIDEMIOLOGY I LECTURE
SCREENING?
February 9, 2025 EPIDEMIOLOGY I LECTURE
February 9, 2025 EPIDEMIOLOGY I LECTURE
CHAPTER SEVEN: SCREENING IN PUBLIC HEALTH PRACTICE
At the end of this session, students will be able
to
• Able to define screening
• Describe criterias for successful screening
• Describe how to evaluate screening program
February 9, 2025 EPIDEMIOLOGY I LECTURE
Screening in Public Health
Practice
Scre
ening
5
Screening
Definition of screening
◦ Presumptive identification of an unrecognized disease or
defect by the application of tests, examinations, or other
procedures.
◦ Classifies asymptomatic people as likely or unlikely to have a
disease or defect
◦ Usually not diagnostic
◦ Diagnosis: Identification of disease during clinical
presentation
Purpose of screening
◦ Delay of onset of symptomatic or clinical disease
◦ Improve survival February 9, 2025 EPIDEMIOLOGY I LECTURE
Screening cont’d....
Seems simple but is complex. There are hidden costs
and risks. Screening can create morbidity and anxiety.
Must be aware of biases.
For screening to be successful you need a:
◦ Suitable disease
◦ Suitable test
◦ Suitable screening program
February 9, 2025 EPIDEMIOLOGY I LECTURE
Types of screening
a) Mass screening – involves screening of a
whole population
b) Multiple or multiphasic screening –
involves a variety of screening tests on the
same occasion.
Types of screening cont…
c) Targeted screening of groups with specific
exposures – is often used in environmental
and occupational health
d) Case-finding or opportunistic screening
– is restricted to patients who consult a
health practitioner for some other purpose
1. Suitable Disease
Suitable disease
◦ Has serious consequences
◦ Is progressive
◦ Disease treatment must be effective at an earlier stage
◦ Prevalence of the detectable pre-clinical phase must be high
◦ Examples of suitable diseases: Breast cancer, cervical
cancer, hypertension
February 9, 2025 EPIDEMIOLOGY I LECTURE
2. Suitable test
Suitable test
◦ Ideally, it's inexpensive, easy to administer, has minimal
discomfort has high level of validity and reliability
◦ Valid Test: Does what it's supposed to do, that is, correctly
classify people with pre-clinical disease as positive and
people without pre-clinical disease as negative
◦ Reliable (precision) Test: Gives you same results on
repetition
◦ Validity is more important than reliability
February 9, 2025 EPIDEMIOLOGY I LECTURE
Validity and Reliability
February 9, 2025 EPIDEMIOLOGY I LECTURE
Validity
Validity of a test:- is the ability to correctly categorize individual
who have preclinical disease as test positive and those with out
pre-clinical disease as test negative
measures of the validity of a screening test
A. Sensitivity
B. Specificity
C. Positive predictive value
D. Negative predictive value
E. Yield
February 9, 2025 EPIDEMIOLOGY I LECTURE
Sensitivity
the ability of a test to correctly identify those
who have the disease
the percentage of those who have the
disease and are proven to have the disease
as demonstrated by a test
is the probability of a positive test in people
with the disease
Sensitivity
Measures of test validity
Sensitivity- enables you to pick up the cases of
Disease
Sensitivity = a/a+c = those that test
positive / all with disease
February 9, 2025 EPIDEMIOLOGY I LECTURE
Specificity
the ability of a test to correctly identify those
who do not have the disease
the probability of a negative test in people
without the disease
Suitable Test cont’d...
Specificity - enables you to pick out the no
diseased people
Specificity = d / b + d = those that test
negative / all without disease
Valid test has high sensitivity and specificity
Scre
ening
17
Two-by –two table for the calculation of validity of screening
tests
Definitive Diagnosis
Screening Diseased Non Total
Test Diseased
TP(a) FP(b) TP+FP(a+b)
Positive
FN(c) TN(d) FN+TN(c+d
Negative )
TP+FN(a+c TN+FP(b+d TP+FP+TN
Total ) ) +FN
(a+b+C+d)
Validity cont…
TP
Sensitivity = X 100
TP+FN
TN
Specificity = X100
TN + FP
Suitable Test cont’d...
Breast Cancer Screening Program - Heath Insurance Plan
HIP) Women assigned to screening or usual care. Screening
consisted of yearly mammogram and physical exam. Five
years of follow-up produced these results: Breast Cancer
Not Total
Confirmed Confirmed
Positive 132 983 1,115
Screeni
ng Negative 45 63,650 63,695
Test Total 177 64,633 64,810
Result
Scre
ening
20
Suitable Test cont’d...
Sensitivity = 132/177 = 74.6%
Specificity = 63,650/64,633 = 98.5%
Interpretation: The screening was very good at
picking out the women who did not have cancer (see
specificity) but it missed 25% of the women who did
have cancer (see sensitivity).
Scre
ening
21
Yield
The yield (number of cases detected by
the screening program).
Persons with the disease
Yield = detected by the test
X
100
Total screened
TP
Yield = X 100
Predictive Value of a Screening Test
Predictive value is the ability of a test to predict the
presence or absence of disease from test results.
1. Predictive Value of a Positive Test (PVPT) or
Positive Predictive Value
probability that the person tested positive by this
specific test truly has the disease.
TP
PVPT = X 100
TP+FP
Predictive Value cont…
2. Predictive Value of a Negative
Test (PVNT) or Negative
Predictive Value
Shows the degree of confidence the
disease can be ruled out by using
this specific test. Or
the probability that an individual is
truly disease-free given a negative
screening test
TN
Predictive Value cont…
The higher the prevalence, the more likely it
is that a positive test is predictive of the
diseases i.e PVPT will be high.
The more sensitive a test, the less likely it is
that an individual with a negative test will
have the disease ( FN), and thus the greater
the predictive value negative.
Predictive Value cont…
The more specific the test, the less likely an
individual with a positive test will be free from the
disease ( FP) and the greater the predictive value
positive.
For rare disease, however, the major determinant of
the predictive value positive is the prevalence of the
preclinical disease in the screened population.
No matter how specific the test, if the population is
at low risk of having the disease, results that are
positive will mostly be false positives.
Evaluation of Screening Program cont’d...
Predictive = A/aa = Number who test
value of a a/a+b positive with
positive test disease/ Number
(PV+) with positive result
Predictive = d/c+d = Number who test
value of a negative without
negative test disease/ Number
(PV-) with negative
result
February 9, 2025 EPIDEMIOLOGY I LECTURE
Evaluation of Screening Program cont’d...
Breast Cancer Screening Program of HIP
Breast Cancer
Cancer Cancer Not Total
Confirmed Confirmed
Positive 132 983 1,115
Screen Negative 45 63,650 63,695
ing Total 177 64,633 64,810
Test
PV+ = 132/1115 = 11.8%
PV- = 63,650/63,695 = 99.9%
Exercise
Table : Sensitivity and specificity of breast cancer screening examination (Health
Insurance Plan of Great New York (HIP Program)
Breast cancer
Cancer cancer not
Total
Confirmed confirmed
Screening
test (Physical
Examination & mammography)
Positive 132 983 1115
Negative 45 63,650 63,695
Total 177 64,633 64,810
Sensitivity = ?
Specificity = ?
PV+ = ?
PV- = ?
Reliability (Precision)
Reliabilityrefers to the consistency of results
when repeat examinations are performed on
the same persons under the same condition.
There are 4 sources of variability that can
affect the reproducibility of results of
screening test:
Reliability cont…
1. Biological variation
inherent in the actual manifestation
being measured such as BP
which varies considerably for a given
individual with time and other
circumstances
2. Variation due to the test method
or measurement
-relates to the reliability of the
instrument itself, such as standard
Reliability cont…
3. Intraobserver variability
-refers to differences in repeated
measurements by the same screener
4. Interobserver variation
-refers to inconsistencies attributable to
differences in the way different screeners
apply or interpret test results
Reliability cont…
These variations can usually be reduced
by:
1. careful standardization of procedures
2. an intensive training period for all
observers (or interviewers)
3. periodic checks on their work
4. the use of two or more observers making
independent observations.
Summary of Screening
Screening is the presumptive identification of
unrecognized disease by the application of tests,
exams, etc.
Suitable disease must be serious with important
consequences and progressive
Scre
ening
34
Summary cont’d...
Suitabletest must have low cost, be acceptable, and
have a high degree of validity
Validity is measured by sensitivity and specificity
Scre
ening
35
Summary cont’d...
Screening programs administer screening tests in
particular populations
Programs are evaluated mainly by examining
predictive value and outcome measures such as stage
distribution and cause-specific mortality
Scre
ening
36
Thank you!
February 9, 2025 EPIDEMIOLOGY I LECTURE