Screening For Disease

SCREENING FOR
DISEASE
Dr. R.Shyam
"Health should mean a lot more
than escape from death or, for
that matter, escape from
disease."
Iceberg phenomenon of disease
◦ The concept of the "iceberg phenomenon of disease" gives a better idea of the progress of a disease
from its sub-clinical stages to overt or apparent disease than the familiar spectrum of disease.
◦ The floating tip represents what the physician sees in his practice. The hidden part of the iceberg thus
constitutes the mass of unrecognized disease in the community, and its detection and control is a
challenge to modern techniques in preventive medicine.
Concept of screening
◦ "the search for unrecognized disease or defect by means of rapidly applied tests, examinations or other
procedures in apparently healthy individuals."
◦ Screening differs from periodic health examinations in the following respects (1):
◦ 1) capable of wide application
◦ 2) relatively inexpensive, and
◦ 3) requires little physician-time. In fact the physician is not required to administer the test, but only to
interpret it.
A screening test is not intended to be a diagnostic test. It is only an initial examination. Those who are
found to have positive test results are referred to a physician for further diagnostic work-up and treatment.
Screening Vs. diagnostic tests
contrasted
Screening test Diagnostic test
1 Done on apparently healthy 1. Done on those with indications or sick.
2 Applied to groups 2. Applied to single patients, all diseases
3 Test results are arbitrary and final are considered.
4 Based on one criterion or cut-off point 3. Diagnosis is not final but modified in light
5 Less accurate of new evidence, diagnosis is the sum of
6 Less expensive all evidence.
7 Not a basis for treatment 4. Based on evaluation of a number of
8 The initiative comes from the investigator symptoms, signs (e.g., diabetes) and
or agency providing care laboratory findings.
5. More accurate.
6. More expensive.
7. Used as a basis for treatment.
8. The initiative comes from a patient with
a complaint.
lead time
◦ There is nothing to be gained in screening for diseases whose onset is quite obvious. Detection
programmes should be restricted to those conditions in which there is considerable time lag between
disease onset and the usual time of diagnosis.
Aims and objectives
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. Screening is carried out in the hope that earlier
diagnosis and subsequent treatment favorably. alters the natural history of the disease in a significant
proportion of those who are identified as "positive"
Uses of screening
Control
of
disease
Case
detection
Research Educational
purposes opportunities
Types of screening
◦ Three types of screening have been described:
a. Mass screening
b. High-risk or selective screening
c. Multiphasic screening.
CRITERIA FOR SCREENING
The criteria for screening are based on two considerations:
◦ the DISEASE to be screened, and
◦ the TEST to be applied
Disease
The disease to be screened should fulfil the following criteria before it is considered suitable for
screening:
1. the condition sought should be an important health problem (in general, prevalence should be
high);
2. there should be a recognizable latent or early asymptomatic stage
3. 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)
4. there is a test that can detect the disease prior to the onset of signs and symptoms
5. facilities should be available for confirmation of the diagnosis
6. here is an effective treatment
7. there should be an agreed-on policy concerning whom to treat as patients (e.g., lower ranges of
blood pressure; border-line diabetes)
8. there is good evidence that early detection and treatment reduces morbidity and mortality
9. the expected benefits (e.g., the number of lives saved) of early detection exceed the risks and
costs.
Screening test
The choice of the test must often be based on compromise:

1. Acceptability
2. Repeatability
3. Validity (accuracy)
Evaluation of a screening test
◦ The following measures are used to evaluate a screening test:
◦ (a) Sensitivity a/ (a + c) x 100
◦ (b) Specificity = d/(b + d) x 100
◦ (c) Predictive value of a positive test = a/(a + b) x 100
◦ (d) Predictive value of a negative test = d/(c + d) x 100
◦ (e) Percentage of false-negatives = c/(a + c) x 100
◦ (f) Percentage of false-positive = b/(b + d) x 100
Predictive accuracy
◦ In addition to sensitivity and specificity, the performance of a screening test is measured by its "predictive value"
which reflects the diagnostic power of the test.
◦ The predictive accuracy depends upon sensitivity, specificity and disease prevalence.
◦ The more prevalent a disease is in a given population, the more accurate will be the predictive value of a positive
screening test.
◦ The predictive value of a positive result falls as disease prevalence declines.
◦ False-negatives: The term "false-negative" means that patients who actually have the disease are told that they do
not have the disease.
◦ False-positives: The term "false-positive" means that patients who do not have the disease are told that they have
the disease.
◦ "Yield" is the amount of previously unrecognized disease that is diagnosed as a result of the screening effort.
◦ Combination of tests Two or more tests can be used in combination to enhance the specificity or sensitivity of
screening.

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SCREENING FOR

The choice of the test must often be based on compromise:

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