Screening For Disease

Screening
Dr.S.Suganthi,
Asst. Professor ,
Dept of Community Medicine,
CHRI
1
Contents
 Iceberg phenomenon
 Concept of screening
 Difference between screening & diagnostic
test
 Concept of lead time
 Aims and objectives
 Uses
 Types
 Criteria
2
Iceberg Phenomenon of Disease
 The submerge portion of the iceberg represents the
hidden mass of the disease (e.g. subclinical cases,
carriers, undiagnosed cases).
 The floating tip represents what the physician sees in
his practice.
3
Concept of Screening
 Defined as "the search for unrecognized
disease or defect by means of rapidly applied
tests, examinations or other procedures in
apparently healthy individuals“
 Screening is an important aspect of prevention,
but not all diseases are suitable for screening
4
Screening and Diagnostic Tests
 A screening test is not intended to be a
diagnostic test.
 Those who are found to have positive test
results are referred to a physician for further
diagnostic work-up.
 There are some tests which are used both for
screening and diagnosis, e.g., test for anemia
and glucose tolerance test.
5
Aim
 The basic purpose of screening is to sort out
from a large group of apparently healthy
persons those likely to have the disease or at
increased risk of the disease under study, to
bring those who are " apparently abnormal"
under medical supervision and treatment.
6
Uses of screening
 a) Case detection - the presumptive identification of unrecognized
disease, which does not arise from a patient's request. To make sure
that appropriate treatment is started early.
 b) Control of disease - People are examined for the benefit of

others, e.g., screening of immigrants from infectious disease such as
tuberculosis and syphilis to protect the home population.
7
Uses of screening
 c.) Research purposes - e.g. cancer, hypertension.
Screening may aid in obtaining more basic
knowledge about the natural history of such diseases.
 d.) Educational opportunities - screening

programs (as for example, screening for diabetes)
provide opportunities for creating public awareness
and for educating health professionals.
8
Types of Screening
 Mass screening
 High risk selective screening
 Multiphasic screening
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Types of Screening
 a.) Mass screening - it is offered to all, irrespective
of the particular risk individual.
10
Types of Screening
b.) High risk or selective screening
 Screening will be most productive if applied selectively to

high risk groups, One population subgroup where certain
diseases (e.g., diabetes, hypertension, breast cancer) tend to
be aggregated is the family. By screening the other members
of the family (and close relatives) the physician can detect
additional cases.
 More recently, epidemiologists have extended the concept of

screening for disease to screening for "risk factors"
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Types of Screening
c.) Multiphasic screening
 The application of two or more screening tests in

combination to a large number of people at one time
than to carry out separate screening tests for single
diseases.
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Issues in Screening
Disease
Disease/disorder should be an important public health problem

High prevalence
Serious outcome
-Early Detection in asymptomatic (pre-clinical) individuals is

possible
-Early detection and treatment can affect the course of disease

(or affect the public health problem?)
13
Criteria for Screening
 Before a screening program is initiated, a decision
must be made whether it is worthwhile, which
requires ethical, scientific and if possible financial
justification.
 The criteria for screening are based on two

considerations:
 DISEASE to be screened
 TEST to be applied.
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1- Disease:
the disease to be screened should fulfill the following
criteria before it is considered suitable for screening:
 The condition sought should be an important health

problem (in general, prevalence should be high)
 The natural history of the condition, including
development from latent to declared disease, should be
adequately understood (so that we can know at what
stage the process ceases to be reversible)
 There is a test that can detect the disease prior to the
onset of signs and symptoms
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Criteria for Screening = The Disease
 Facilities should be available for confirmation of the
diagnosis
 There is an effective treatment
 There is good evidence that early detection and
treatment reduces morbidity and mortality
 The expected benefits (e.g, the number of lives saved) of
early detection exceed the risks and costs.
 When the above criteria are satisfied, then only, it would
be appropriate to consider a suitable screening test.
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2- Screening test
 The test must satisfy the criteria of:
 Acceptability
 Repeatability
 Validity
 Simplicity
 Safety
 Rapidity
 Ease of administration
 Cost.
17
Criteria for Screening = Screening Test
1) Acceptability
 Since a high rate of cooperation is necessary, it is
important that the test should be acceptable to the
people at whom it is aimed.
 In general, tests that are painful, discomforting or
embarrassing (e.g. rectal or vaginal examinations) are
not likely to be acceptable to the population in mass
campaigns
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2.) Repeatability
 An attribute of an ideal screening test or any
measurement (e.g. height, weight) is its repeatability
(sometimes called reliability, precision or
reproducibility).
 That is the test must give consistent results when
repeated more than one on the same individual or
material, under the same conditions.
 The repeatability of the test depends upon three major
factors, namely observer variation, biological (or
subject) variation and errors relating to technical
methods.
19
A. Observer variation
 Types:
 1.) Intra-observer variation : or within observer

variation. This is a variation between repeated
observations by the same observer on the same subject
or material at the same time. Intra-observer variation
may often be minimized by taking the average of
several replicate measurements at the same time
 2.) Inter-observer variation: This is a variation
between different observers on the same subject or
material, also known as between observer variation.
20
Observer errors can be minimized by:
 Standardization of procedures for obtaining
measurements and classifications
 Intensive trainings of all the observers
 Making use of two or more observers for independent

assessment, etc
 It is probable that these errors can never be eliminated
absolutely.
21
B. Biological (subject) variation
 The fluctuation in the variate measured in the same

individual may be due to:
 (a) changes in the parameters observed. For example,
subject variation of blood pressure is a common
phenomenon.
 (b) variations in the way patients perceive their
symptoms and answer
 Whereas observer variation may be checked by repeat
measurement at the same time, biological variation is
tested by repeat measurements over time.
22
C. Errors relating to technical methods
 Lastly, repeatability may be affected by variations

inherent in the method, e.g. defective instruments,
erroneous calibration, faulty reagents; or the test
itself might be inappropriate or unreliable.
23
3. Validity (accuracy)
 The term validity refers to what extent the test
accurately measures which it purports to
measure.
 In other words, validity expresses the ability of a test
to separate or distinguish those who have the disease
form those who do not
 Validity has two components : sensitivity and
specificity
24
 Sensitivity - the ability of a test to identify correctly
all those who have the disease, that is "true positive".
A 90% sensitivity means that 90% of the diseased
people screened by the test will give a "true positive".
 Specificity - is defined as the ability of a test to

identify correctly those who do not have the disease,
that is " true negatives". A 90% specificity means that
90% of the non-diseased people give "true negative"
25
26
27
28
Principles for Screening Programs
1. Condition should be an important health problem

2.There should be a recognizable early or latent stage
3.There should be an accepted treatment for persons with
condition
4.The screening test is valid, reliable, with acceptable yield
5.The test should be acceptable to the population to be screened
6.The cost of screening and case finding should be
economically balanced in relation to medical care as a
whole
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Screening

 b) Control of disease - People are examined for the benefit of

 d.) Educational opportunities - screening

 High risk selective screening

 Screening will be most productive if applied selectively to

 More recently, epidemiologists have extended the concept of

 The application of two or more screening tests in

Disease/disorder should be an important public health problem

-Early Detection in asymptomatic (pre-clinical) individuals is

-Early detection and treatment can affect the course of disease

 The criteria for screening are based on two

 The condition sought should be an important health

 1.) Intra-observer variation : or within observer

 Making use of two or more observers for independent

 The fluctuation in the variate measured in the same

 Lastly, repeatability may be affected by variations

 Specificity - is defined as the ability of a test to

1. Condition should be an important health problem

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