SCREENING OF DISEASE

DR SAMANTHASRI
DR KARUNYA
1st year postgraduates,
Department of Community
Medicine.
GUIDE - DR.KRISHNA PRASANTH
1

Asst Professor,SBMCH
 OVERVIEW
 Iceberg Phenomenon  Concept of lead time
of disease  Screening v/s
 Definition diagnostic tests
 process of screening  Types of screening
 Concept of screening  Uses of screening
 Criteria for screening
test
 References
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 BASIS OF SCREENING
BASIS OF SCREENING
Iceberg phenomenon of
disease
tip of the iceberg
CLINICAL DISEASE

submerged portion
HIDDEN BURDEN OF
DISEASE

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 DEFINITION

“The presumptive search for

unrecognized defect or disease by
means of rapidly applied tests,
examinations or other procedures
in apparently healthy individual to
identify who probably have a
disease, from those who probably 4

do not”
 Screening is an active search made for -detecting the hidden
disease among apparently healthy individuals in the community by
means of rapidly applied test

 for gaining lead time in treatment of a disease ,for

secondaryprevention or control of spread

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 AIMS & OBJECTIVES

 Aim of the screening programme is the early

detection of unrecognized disease in
apparently healthy individuals.

 Objective of screening provides a means for

secondary prevention of disease.
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Process of screening

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 CONCEPT OF SCREENING

Wide population
Minimal expenditure
Minimal time
Requires less physicians time. In fact the physician is
not required to administer the test, but only to
interpret it
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Lead Time

• The LEAD TIME is defined as the interval by which the

time of diagnosis is advanced by screening and early
detection of disease compared to the usual time of
diagnosis.

• Lead time is the advantage gained by screening i.e. the

period between diagnosis by early detection and diagnosis
by other means.
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 Concept of lead time:

First
Disease onset Final critical Usual time of
possible
detection diagnosis diagnosis OUTCOME
point

B
Screening time

Lead time
A – usual outcome of the disease
B – advantage gained by early detection of the disease 11

B-A – benefit by the screening programme.

Example :if a women undergoes regular mammograms and is
diagnose with breast ca through screening at age 50 but if the cancer
would have been detected through symptoms at age 55

here the lead time would be 5 yrs so the adavantgage gained by

screening is 5 yrs before it progresses further

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ERRORS WITH SCREENING

1. LEAD TIME BIAS - the systematic error of apparent

increased survival from detecting disease in an early stage.

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2. LENGTH TIME BIAS
Diseases with a long pre-clinical phase are more likely to be
detected during screening. Moreover, pre-clinical phase for
the same disease may be variable in different individuals .

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 Example
 A patient selected with slowly progressing disease are
more likely to be detected during screening
 fast progressing disease are not detected by screening

 Here screening causes different outcomes rather than the

disease progression

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• Screening test - specific technology used to help identify persons with
unrecognized disease or unrecognized risk factors for disease.
• Diagnostic test - use of clinical and/ or laboratory procedures to confirm
the existence of disease or true abnormality in patients with signs and
symptoms presumed to be caused by the disease.
mammogram for ca breast( screening test)

positive

biopsy ( diagnostic test) 18

Example – SCREENING vs DIAGNOSTIC
TEST for CA BREAST

a mammogram is a routine test many women undergo

regularly even if they don’t have any symptoms it is done to
check any signs for breast cancer before it cause any
noticeable problems

biopsy is a diagnostic test to confirm the screening test

if cancer is present which helps to determine the type and
stages which helps for further treatment process
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TYPES OF SCREENING

1. MASS SCREENING

Application of screening test to large, unselected population.

Everyone in the group is screened regardless of the probability of
having the disease or condition.

Example: a) visual defects in school children

b) mammography in women aged 40 years or less
c) newborn screening program
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2. HIGH RISK / SELECTIVE / TARGETED SCREENING
The screening of selected high-risk groups in the population.

Example: a) screening fetus for Down’s syndrome in a

mother who already has a baby with down’s syndrome

b) screening for familial cancers, HTN and DM

c) screening for CA Cervix in low SES women

d) screening for HIV in risk groups

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 TYPES OF SCREENING- contd..
 3.MULTIPURPOSE SCREENING - the screening of a
population by more than one test done simultaneously to
detect more than one disease

e.g: a) Screening of pregnant women for VDRL(syphilis),

HIV, Hep B Virus by serological tests


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 TYPES OF SCREENING- contd..
4.MULTIPHASIC SCREENING -Two or more screening
tests in combination to a large no of people at one time
than to carry out separately for single disease.

Example: Chemical and hematological tests on blood

and urine specimens, LFT, audiometry, and
measurement of visual acuity.

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 TYPES OF SCREENING- contd..

5. MULTISTAGIC SCREENING
When multiple screening tests are applied in stages to screen for a single
disease .
Example: In TB, 1st Monteux test is done if it is positive then chest x-
ray, if positive findings then sputum test .

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 TYPES OF SCREENING- contd..

6. OPPORTUNISTIC / CASE FINDING SCREENING

The person has come to the provider for a particular disease but the provider
utilizes this opportunity to screen the person for different disease which he
has signs and symptoms.
The main objective is to detect disease and bring patients to treatment

Example: RHD screening in a child with sore throat presentation

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 USES OF SCREENING

 CASE DETECTION - “Prescriptive screening” presumptive

identification of disease which does not arise from patients
request. People are screened for their own benefit. (Iron def
anemia, TB,Hypertension)
 CONTROL OF DISEASE – “prospective screening”,
people are screened for the benefit of others.(screening
immigrants for Yellow Fever, STI, COVID19)

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 USES OF SCREENING- contd..

 RESEARCH - To know the natural history of a disease

(cancer, hypertension)

 EDUCATION - public awareness & Educating heathcare

professionals (Screening for Diabeties)

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 CRITERIA FOR SCREENING

1. DISEASE
 Should be an important health problem(prevalence should be
high)
 Detectable and long preclinical stage of disease
 Adequately understood natural history of disease
 Appropriate test available for early detection of disease

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 CRITERIA FOR SCREENING
 Facilities for diagnosis of disease

 Evidence that early detection of disease has outcome

benefits

 Effective treatment available for disease

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 CRITERIA FOR SCREENING

2. SCREENING TEST
 Simplicity
 Acceptable
 Yielding
 Validity
 Reliable
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 SIMPLICITY

 The test should be simple to perform, easy to interpret and

where possible, capable to use by paramedics and other
personnel.

Eg. Blood, urine tests and ECG for early detection of

hypertension.

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 ACCECPTABLE

 ACCECPTABLE-High rate of coopperation is necessary. It

should be acceptable to the people it is aimed. Generally
tests that are painful, embarssing & are not likely to be
acceptable.

Example-Per rectal or Vaginal examinations.

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 YIELDING

 YIELD - The amount of previously unrecognized disease that

is diagnosed as as result of the screening effort.

 It depends on the sensitivity & specificity of the test &

prevalence.

Example - Diabeties for over 40 years,we can increase the

yield of the screening test.
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 REPEATABILITY
 The test must give consistent results when repeated more
than once on the same individual or material, under the
same conditions.
 Depends on 3 major factors:

➢Observer variation.
➢Biological variation
➢Errors relating to technical methods.
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SCREENING TEST (CONT) :
Observer variation :
 Intra observer: This is variation between repeated
observations by the same observer on the same subject
or material at the same time.
Intra-observer variation can be minimized by taking the
average of several replicate measurements
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 Inter observer: This is variation between different
observers on the same subject or material.
Common in – X-rays, ECG, histo-pathological
specimens, BP readings etc.
we therefore need to be able to express the extent of
agreement in quantitative terms
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Biological variation :
 Intra subject variation : Is the variation in the results
of a test conducted
over a short period of time on the same individual
 The difference is due to changes (such as
physiological ,environmental etc.,)
occurring to that individual over that time period.

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SCREENING TEST (CONT) :
 Errors in technical method: variations inherent in the
method
Defective instruments.
Errors in calibration.
Faulty reagents.
Test itself may be inappropriate or unreliable.
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 VALIDITY

 Validity determines the accuracy of the test.

 A test with little systematic error is a valid test

Components of VALIDITY:
 SENSITIVITY
 SPECIFICITY

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CRITERIA FOR SCREENING

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 REFERENCE

1. K Park. Principles of Epidemiology and Epidemiologic methods.

In: Park’s Textbook of Preventive and Social Medicine; 26th edn.
Jabalpur; M/s Banarsidas Bhanot Publisher.
2. Gordis Leon, Textbook of epidemiology. 6th edition.
3. IAPSM’s Textbook of Community medicine,2nd edition.

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