Screening

Community Medicine
Learning Objectives:
O At the end of today’s discussion, all the
students must be able to:
1. Define iceberg phenomenon of disease,
screening and lead time.
2. Describe uses and / or types of screening
and differentiate between screening as
well as diagnostic tests.
3. Explain Wilson's criteria for screening, yield
and characteristics of screening tests.
4. Interpret 2x2 contingency table for
screening tests.
 Iceberg Phenomenon of
Disease:
O Certain diseases in the community behave like
an iceberg.
O Physician can only see the diseased persons
who report to him (the clinical cases); while
the vast majority of disease burden is hidden
in the form of sub-clinical, unrecognized,
undiagnosed cases as well as disease carriers.
O We can detect the sub-clinical, unrecognized,
undiagnosed cases as well as disease carriers
with the help of screening test for the
respective disease.
Definition of Screening:
O Screening is the search for
unrecognized disease or defect /
undiagnosed cases of a disease by
means of rapidly applied tests,
examinations or procedures in
apparently healthy population for
control and prevention.
Definition of Lead time:
O Lead time is the interval between
detection of disease at screening
and when it would have been
detected due to the development of
signs / symptoms (usual time of
diagnosis).
O Lead time is the benefit available to
the physician for early management
of disease.
 Benefits / Uses
of Screening test:
1. The early a disease is detected; the
early management of disease can
change the course and prognosis of
the disease (Prospective screening
= For control of disease).
2. Case detection = We can save
other persons, if the disease is
communicable (Prescriptive
screening = For prevention).
3. For research and educational
purposes.
 Types of Screening:
1. Mass / Census screening: means
screening of whole population i.e. Offered
to all.
2. Opportunistic screening: is the
screening of a person who has reported to
the physician for some sort of ailment and
physician finds opportunity to screen that
patient for some other disease. For
example; a patient comes for herneoraphy
and surgeon finding opportunity screens
that patient for hepatitis B, C and HIV.
 Types of Screening:
O 3. High risk or selective screening: is applied
to high risk groups rather than to whole
population. For example; screening for diabetes
mellitus will be more productive if only high risk
group (obese, age > 50 years and positive family
history) is targeted.
O 4. Accidental screening: is accidental detection
of a disease in otherwise apparently healthy
person on medical examination / lab tests / x-
rays. Medical examination was carried out as a
requirement for going abroad for studies or
performing Hajj or Umrah or for employment.
 Types of Screening:
O 5. Multi-phasic screening: is the
application of two or more screening
tests to a community at one time. It
is done for the purpose of cost-
effectiveness.
Difference between Screening
and Diagnostic tests:
S. Screening test: Diagnostic test:
No
:
1. Applied to large Applied to single
population patient
2. Done on apparently Done on sick
healthy
3. Less expensive More expensive
4. Less accurate More accurate
5. Less time consuming More time
consuming
6. Not a basis to start Basis for treatment
treatment
7. Results are final Results are not final
 Diseases against which
Screening is done:
O In Pakistan; one can plan for
screening against:
1. Pulmonary Tuberculosis
2. Ischemic heart disease
3. Thalassemia
4. Hypertension
5. Diabetes
6. Hepatitis B and C
 Wilson’s Criteria for
Screening of a disease:
1. Disease should be a major public
health problem
2. Disease should be relatively prevalent
3. There should be a suitable diagnostic
test available
4. There should be an accepted
treatment available for the disease
5. There should be a recognized latent
or early stage
 Wilson’s Criteria for
Screening of a disease:
O 6. Disease should not have short
incubation period
O 7. Test / examination should be
acceptable to the people
O 8. There should be an agreed policy on
whom to treat
O 9. Costs should be balanced in relation
to overall expenditure on medical care
O 10. Case finding should be a continuous
process
 Characteristics of a
screening test:
1. Acceptability
2. Repeatability (Reliability, Precision,
Reproducibility)
3. Validity or Accuracy has two components:
 Sensitivity is the ability of the test to
differentiate those who have the disease
i.e. True positives.
 Specificity is the ability of the test to
differentiate those who do not have the
disease i.e. True negatives.
Yield of Screening test:
O It is the number of persons found
disease positive on screening test,
which were previously remained
unrecognized / undiagnosed.
Ideal Screening test:

OShould be 100% sensitive and

100% specific, but in practice

there is no such test available.
2x2 Contingency table for
Screening test:
Diagnostic test results:

Screening test a (True positive) b (False positive)

results:
c (False negative) d (True negative)
OTrue Positive, False Positive, True

Negative, and False Negative

results are used to calculate
sensitivity, specificity, and predictive
values of diagnostic tests.
O True Positive (TP) = positive test result

for a person who has the condition

O False Positive (FP) = positive test result

for a person who does not have the

condition
O True Negative (TN) = negative test result

for a person who does not have the

condition

O False Negative (FN) = negative test result

for a person who has the condition

2x2 Contingency table for
Screening test:
O a + b = All screening test positive
persons
O c + d = All screening test negative
persons
O a + c = All diseased persons
O b + d = All healthy persons
On = a + b + c + d
 Formulas:
O Sensitivity = a / a + c x 100
O Specificity = d / b + d x 100
O Positive predictive value = a / a + b
x 100
O Negative predictive value = d / c + d
x 100
O Accuracy or Validity = a + d / n x
100
O Prevalence = a + c / n x 100
Relationship of Sensitivity
and Specificity:

O They are often inversely related. If

we increase sensitivity, then

specificity will decrease and vice-

versa.
OPredictive value describes
the likelihood that a person has
or does not have the
condition based on the results of
the test. The more prevalent the
disease, the higher the PPV and
the lower the NPV.
 Positive Predictive
Value
O Positive Predictive Value (PPV) is

the likelihood that a person with a

positive test result truly has the

disease.

O PPV=TP/TP+FP
O If a test for a particular disease has a

PPV of 80%, it means that 80% of the

people who test positive actually have

the disease.
O Importance:
O PPV is a crucial metric for evaluating
the accuracy and reliability of
diagnostic tests, especially when
dealing with conditions that may have
a low prevalence in the population
Negative Predictive
Value
O Negative Predictive Value

(NPV) is the likelihood that a

person with a negative test

result truly does not have the

disease.

O NPV=TN+FN
O A high NPV provides reassurance to
patients and clinicians that a
negative test result truly indicates
the absence of the disease.
O Example:
O If a screening test for a disease has a
high NPV, it means that if a person
tests negative, they are very likely to
be free of the disease.
Questions?

O Thanks!!!