SCREENING

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

 Specific learning objectives

• At the end of this session, the student should be

able to –
– Define screening

– Describe Wilson’s criteria for screening

– Describe diagnostic parameters (sensitivity, specificity

etc.)

– Demonstrate the calculation and interpretation of

diagnostic parameters.
 DEFINITION

• Screening is a process of identifying apparently

healthy people in the population who may be at
increased risk of a disease or a health condition.
– They can then be offered information, further tests and
appropriate treatment to reduce their risk and/or any
complications arising from the disease or condition.
How the process of Screening occurs
 Wilson and Jungner’s classic screening criteria

• The disease should be an important public

health problem.

• There should be an accepted treatment for

patients with recognized disease
– If there is no treatment, it is premature to institute
screening
• Facilities for diagnosis and treatment should be
available
– It is unethical to screen without providing possibilities for
follow-up

• There should be a recognizable latent or early

symptomatic stage
– If early detection does not improve survival, there is no
benefit from screening
• There should be a suitable test for examination,
with sufficient sensitivity and specificity to be of
use in identifying new cases

• The test should be acceptable to the population

• The natural history of the condition, including

development from latent to declared disease,
should be adequately understood
• There should be an agreed-upon policy
concerning whom to treat as patients

• The cost of case-finding should be economically

balanced in relation to possible expenditure on
medical care as a whole

• Case-finding should be in a continuing process

and not a one-time project
• Wilson’s Screening criteria
i. Important health problem
ii. Accepted treatment for recognized disease
iii. Facilities for diagnosis and treatment
iv. Suitable latent and symptomatic stage
v. Suitable test or examination
vi. Test acceptable to population
vii. Natural history of condition understood
viii. Agreed on policy on whom to treat
ix. Cost of finding economically balanced with overall
health
x. Case finding should be continuous process
 SOME SCREENING PROGRAMS

Pap smear
 Principles underlying the screening tests

• SENSITIVITY is defined as the ability of the test to detect

all those with disease in the screened population.

• This is expressed as the proportion of those with disease

correctly identified by a positive screening test result

• Sensitivity = number of true positives = a/ (a+c)

total with disease
 2 * 2 Table
Disease status as determined by ‘Gold Standard’

Disease +nt Disease -nt

Positive
True +ve False +ve Total test
Test +ve predictive
(a) (b) positive (a+b)
value

Negative
False –ve True –ve Total test
Test -ve predictive
(c) (d) negative (c+d)
value

Total with Total without Total screened

disease (a+c) disease (b+d) (a+b+c+d)

Sensitivity Specificity
 COMMUNITY

SCREENING TEST

ASSESSMENT OF
SENSITIVITY
 100% SENSITIVITY

SCREENING TEST
 75% SENSITIVITY

SCREENING TEST
• SPECIFICITY is defined as the ability of the test to
identify correctly those free of disease in the screened
population.

• This is expressed as the proportion of those without

disease correctly identified by a negative screening test
result
• Specificity = number of true negatives = d/ (b+d)
total without disease
SCREENING TEST

ASSESS SPECIFICITY
SCREENING TEST

100% SPECIFICITY
SCREENING TEST

66.67% SPECIFICITY
• POSITIVE PREDICTIVE VALUE (PPV)

• The proportion of patients who test positive

who actually have the disease.
• This is expressed as the proportion of those with
disease among all screening test positives.

• PPV = number of true positives = a / (a+b)

total test positives
• NEGATIVE PREDICTIVE VALUE (NPV)

• The proportion of patients who test negative

who are actually free of the disease.
• This is expressed as the proportion of those
without disease among all screening test
negatives.

• NPV = number of true negatives = d / (c+d)

total test negatives
 Applying the concept of predictive values to screening tests

• Assume a population of 1000 people

• 100 have a disease
• 900 do not have the disease
• A screening test is use to identify the 100 people with the
disease
• The results of the screening appear in this table
Screening True characteristics in the population
results Total
Disease present Disease absent
Test positive 80 100 180
Test negative 20 800 820
total 100 900 1000
 Calculating predictive values

Positive Predictive value = 80/180 = 44%

Screening True characteristics in the population

results Total
Disease present Disease absent
Test positive 80 100 180
Test negative 20 800 820
total 100 900 1000

Negative predictive value = 800/820 = 98%

 The effect of disease prevalence
• Sensitivity and specificity are independent of the
prevalence of the disease, i.e., TEST SPECIFIC (they
describe how well the screening test performs against
the gold standard).
• PPV and NPV, however, are disease prevalence
dependant, i.e., POPULATION SPECIFIC.
– PPV and NPV give information on how well a
screening test will perform in a given population with
known prevalence.
– Generally, a higher prevalence will increase the PPV
and decrease the NPV.
 ELISA test to screen HIV

HIV
Infected Not Infected
cases cases

+ve 9990 (a) 10 (b)

ELISA TEST
-ve 10 (c) 9990 (d)

10,000 (a+c) 10,000 (b+d)

Calculate sensitivity and
specificity
 HIV
Infected Not Infected

+ve 9990 (a) 10 (b)

ELISA TEST
-ve 10 (c) 9990 (d)

10,000 (a+c) 10,000 (b+d)

Sensitivity Specificity
= a/(a+c) = b/(b+d)
= =
9990/(9990+10) 9990/(9990+10)
= 99.9% = 99.9%
 HIV
Infected Not Infected

Test Positive
+ve 9990 (a) 990 (b) positives
a+b Predictive Value
ELISA
TEST
Test Negative
-ve 10 (c) 989010 (d) negatives
c+d Predictive Value

10,000 (a+c) 999000 (b+d)

Sensitivity Specificity
= 99.9% = 99.9%
 HIV
Infected Not Infected
Positive Predictive
Test Value= a/(a+b)
+ve 9990 (a) 990 (b) positives
= 9990/(9990+990)
a+b
=91%
ELISA
Negative Predictive
TEST Value=
Test
-ve 10 (c) 989010 (d) negatives d/(c+d) =989010/(10
c+d +989010)
= 99.9%

10,000 (a+c) 999000 (b+d)

Sensitivity Specificity
= 99.9% = 99.9%
 Which is Preferred: High Sensitivity or
High Specificity?

✓ If you have a fatal disease with no treatment

(such as for early cases of AIDS), optimize
specificity.

✓ If you are screening to prevent transmission of a

preventable disease (such as screening for HIV
in blood donors), optimize sensitivity.
 Example: Breast Cancer Screening

Breast Cancer
Mammogram Disease No Disease Total
Results
Positive 132 983 1,115

Negative 45 63,650 63,695

Total 177 64,633 64,810

Suppose You Are Faced With the Following
Brain Teaser

• In a given population of 1,000 persons, the

prevalence of Disease X is 10%. You have a
screening test that is 95% sensitive and
90% specific.
• What is the positive predictive value?
• What is the efficiency of the test?
 Suppose You Are Faced With the Following
Brain Teaser (cont.)
1) Set up a 2x2 table
True Diagnosis of Disease X
Test Results Disease No Disease Total

Positive
True Positive False Positive
Negative
False Negative True Negative

Total 100 900 1000

Suppose You Are Faced With the Following
Brain Teaser (cont.)
True Diagnosis of Disease X

Test Results Disease No Disease Total

Positive 95 90 185

Negative 5 810 815

Total 100 900 1000

Fill in the missing cells and calculate sensitivity and
specificity for this example

True characteristics in a
Screening population
Total
results Disease Disease
present absent

Test positive 240

Test negative 600

Total 300 700 1000

 Principles Underlying Screening Programs

• Yield – the amount of previously unrecognized

disease that is diagnosed and brought to treatment
as a result of the screening program.

• Reliability – the ability of a test to give consistent

results when performed more than once on the
same individual under the same conditions