Screening programs for

diseases prevention and control

Rahel M.(BSc, MPH)

May, 2022
1 Debre Tabor, Ethiopia
 Learning objectives
At the end of the section students will be able to:

 Explain the purposes of screening

 Discuss the criteria for introducing a screening test

 Calculate and interpret the measures of accuracy of

screening test

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 Introduction

o Screening is defined as “the search for unrecognized

disease or defect by means of rapidly applied tests,

examinations or other procedures in apparently healthy

individuals”

o Test is any device, machine or process designed to detect

a sign, a substance, or a tissue change

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 introduction…
o Screening test is the early detection of disease,

precursors to disease, or susceptibility to disease in

individuals who do not have signs and symptoms of
a disease

o The aim of screening test is to identify

asymptomatic disease, or risk factors for disease,
by testing a population that has not yet developed
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clinical manifestations
 Screening and diagnostic tests

o Diagnostic and screening tests are useful for a

decision to initiate or continue a therapeutic or
preventive intervention in the
individual/community

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 Screening Process
Population
(or target group)
Screening
test

Test Negative Test Positive

Diagnostic test

Unaffected Affected

Intervene
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 Screening test
o Differentiates apparently healthy but diseased
individuals from those that probably do not have
the disease
– Screening test is done in individuals with no such symptoms or
signs
– Screening test is done on apparently healthy persons
– Not diagnostic of a disease
– Positives are investigated further and/or managed
The objective is early detection of a disease
condition in apparently healthy individuals

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 Diagnostic test
o Diagnostic tests are used to confirm the presence
or absence of illness, provide prognostic
information, and predict a response to treatment
o Identify and confirm a disease condition in
individuals
– Diagnostic test is performed in persons with
symptoms or a signs of an illness
– Tests performed in patients
– The objective is case finding within a population
that is probably “diseased”
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 screening VS diagnostic test
screening diagnostic
1. Sort out apparently well 1. Test used for the
persons purpose of diagnosis of
2. Don’t intended to use for disease
diagnosis 2. It carries more risk
3. Help to refer those with 3. Is more expensive than a
positive result to their screening test
physician for their diagnosis 4. Diagnostic test mostly
and treatment employed on
4. Less accurate symptomatic persons
5. Initiative comes from the 5. For confirming diagnosis
investigator 6. More accurate
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Natural history of disease and time of screening

Usual Time Late diagnosis

of diagnosis

Exposure Pathologic Onset of

changes symptoms

Stage of Stage of Stage of Stage of recovery,

Susceptibility sub-clinical disease Clinical disease disability or death

Time of Screening
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 Objectives of screening program

o To alter the natural course of disease for a better

outcome

o To reverse, halt, or slow the progression of a disease to

its severe form and to improve quality of life

o To reduce morbidity and mortality through early

detection and treatment

For primary and secondary prevention of disease

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 Objectives of screening program..

o To protect society from contagious disease

o For rational allocation of resources
o Research opportunity: study on natural history of
disease
o Selection of healthy individuals usually for
employment
E. g: Military and driving license …

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 Types of screening programme
1. Mass screening
– It is offered to all, irrespective of the particular risk factors
2. Multiple/multi-phase screening
– The purpose of two or more screening tests in combination to a
large number of people at one time
3. Case finding/opportunistic screening
– It is restricted to patients who consult a health professional for
some other purposes
4. Targeted/high risk screening
– High risk or selective screening
– It will be most productive if applied selectively to high risk
groups e.g. ANC, PNC

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 Criteria for selection of screening program
1) Important public health problem
2) The target disease has long recognizable pre-symptomatic
stage
3) The natural history should be well understood
4) There should be a detectable early stage
5) There should be a suitable test for the early stage with high
validity, sensitivity, specificity, inexpensive and safe
6) Effective treatment exists and is effective ways of preventing
spread of disease
7) The test should acceptable to the population
8) There should be accepted treatment for patients with
recognized disease
9) Facilities for diagnosis and treatment should be available
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 Evaluating screening Test Performance
Ideally screening tests should be :

 should be inexpensive

 easy to administered

minimum discomfort

the result must be valid ,Reliable& rapid

High accuracy and performance and acceptable

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 Evaluating screening Test Performance

Accuracy (validity and precision) is the ability of the

test to correctly classify individuals according to their
disease status

o Validity is the ability of a test to come up with a result

which is closer to the actual value

o Reliability is the ability of a test to come up with similar

values upon repeated measurements in similar occasions

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 Validity of a Screening Test

 Validity of a test:- is the ability to correctly

categorize individual who have pre-clinical disease
as test positive and those with out pre-clinical
disease as test negative
 Two measures of the validity of a screening test are:-

1. Sensitivity
2. Specificity

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 Sensitivity
is the ability of a test to identify correctly those who have the disease
- identify true positive.
-independent of non- diseased
 High sensitivity preferred for disease with potentially bad
outcomes not to miss cases

FN – corresponds with type I error

 highly sensitivity used for:-
 Serious disease
 For rare disease
 Easily spreadable disease
 But results false positive result
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 Specificity
-is the ability of a test to identify correctly those who do not have the disease
- identify true negative.
- independent of diseased
• High specificity preferred for disease associated with stigma and high cost and danger
of investigations
- can be calculated as

FP corresponds to type II error

 highly specific test is required for
• confirmation
• But results false negative
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 True Diagnosis
Cases Non-cases

Positive 140 1,000 1,140

Screening
a b
Test c d
Results 19,000 19,060
Negative 60

200 20,000
True positives 140
Sensitivity = = = 70%
TP+FN 200
Specificity = True negatives = 19,000 = 95%
TP+FP 20,000
 Consequences of false negative in screening
•Patients with disease will not be treated, resulting in
suffering, spread of disease and death
•Patient may lose confidence in the programme

 Consequences of false positive in screening

• Patients are started on treatment unnecessarily
• Treatment is continued longer than necessary, in follow-
up examinations
• Medications will be wasted
• Patients lose confidence in the program
23 • Suffer with drug complication
  One screening test could not have high Sensitivity
and specificity.
 To address this problem
 Use several screening test together(

Use of multiple test)

 Those are Commonly done in medical practice
 choices depend on cost, invasiveness, presence and capability of
lab infrastructure, urgency, etc.
 can be done sequentially or simultaneously

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 Parallel test ….
I. Test in parallel:-
 perform different test at the same time
 person positive result at any test consider positive
 generally increase sensitivity and decrease specificity

• Parallel testing results in increased sensitivity compared

with that of each individual test
• It lower specificity because false positive diagnoses are also more
likely
 Net sensitivity = Sensitivity 1 + Sensitivity 2 –
(Sensitivity 1 x Sensitivity 2)
 Net specificity = specificity 1 x specificity 2

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 II. Test in series :-
 one initial screening test is performed
 only person positive test are reevaluated with
additional screening test
 generally increase specificity and decrease sensitivity
 Reduce the problem of false positives
 First a less expensive, less invasive, or less
uncomfortable test is generally performed
 Net sensitivity = Sensitivity 1 x Sensitivity 2
 Net specificity = Spec1 + Spec2 –(Spec1 x Spec2)

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 Test in series conti…

• Useful when large number of “false positives” are

expected
– And you cannot afford to do the diagnostic test on that many
FP’s
• Cheaper and less invasive than “gold standard”
• Reduce the problem of false positives
• First a less expensive, less invasive, or less uncomfortable
test is generally performed
• Loss in net sensitivity
• Gain in net specificity

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 Eg. School nurse examined a population of 2,000
school children in an attempt to detect (preclinical)
heart disease. Assume that the prevalence of heart
disease in this school age population is known to be
10%. The sensitivity of the nurse’s examination is
80% and specificity is 80%. All school children who
are labeled as positive (that is suspected of having
heart disease) by the school nurse are later sent for
examination by a physician. The sensitivity of the
physician’s examination is 90%, and its specificity is
also 90%.
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 A. Complete a 2x2 table of nurse’s diagnosis by heart
disease status
B. How many children were labeled “positive” by the
school nurse?
C. Of those sent to the physician, how many children
were labeled “positive”?
D. What is the net sensitivity of both examinations
combined?
E. What is the net specificity of both examinations
combined?

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 Solution
 Prevalence = total disease/total population
 Prevalence= true positives + false negatives
 Given , prevalence=10%
total population =2000
diseased(TP+FN)=total population*prevalence=200
Non-diseased =total population -diseased
= 2000-200=1800
sensitivity =80%
specificity=80%

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 For nurse result
Sensitivity-=true positive/prevalence
True positive(a)=sensitivity x total disease
=0.8x200=160
false negative =total disease – true positive
=200-160= 40
Specificity= true negative/non-diseased
true negative=0.8 x 1800= 1440
 False positive =1800-1440= 360

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  For physician
 Keep the prevalence 10 %
 Sensitivity and specificity=90%
 Total population for physician =true positive + false positive
from the nurse result
 = 160 +360= 520
 Total diseased =520 x0.1=52
 sensitivity=true positive /total diseases
 true positive=0.9x52=47
 Net sensitivity = Sensitivity 1 x Sensitivity 2
 =(0.8x0.9)x100=72%
 Net specificity = Spec1 + Spec2 –(Spec1 x Spec2)
 =0.8 +0.9-(0.8x0.9)=0.98=98%
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 Sensitivity and specificity are affected by

• Degree of skill
• Equipment
• Reagent
• Severity, range of manifestation of disease
• Presence of other disease
• Predictive value, however, is very much
affected by the prevalence of a disease.

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 Choosing appropriate test
Choose a test with a high sensitivity and high negative
predictive value to rule out a diagnosis in the early
stage of the investigation
 When a False Negative is DANGEROUS or SERIOUS

 Choose a test with a high specificity and high positive

predictive value to confirm a diagnosis

o When a False Positive is DANGEROUS or SERIOUS

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Choosing appropriate test
High sensitivity High specificity

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 B. Predict value of a Screening Test

–Predictive value is the ability of a test to

predict the presence or absence of
disease from test results.

–Predictive Value of a Positive test(PV⁺)

–Predictive Value of a Negative Test(PV

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 Predict values
 Positive predictive value (PPV)-The proportion of
patients who test positive who actually have the
disease
 If a person tests positive, what is the probability that
he or she has the disease?
 Negative predictive value (NPV)The proportion of
patients who test negative who are actually free of
the disease
 (And if that person tests negative, what is the
probability that he or she does not have the disease?)

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 True Disease Status
Cases Non-cases
True False
Positive positive positive a+b
Screening
a b
Test c d
Results False True
Negative c+d
negative negative

a+c b+d
True positives a
PPV = =
All positives a+b
True negatives d
NPV = =
All negatives c+d
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  Predictive value depend on

 specificity of test

 sensitivity of test

 prevalence of the disease in the community

 High specificity= increase PV⁺

because lower number of false positive

 High sensitivity test=increase PV⁻

because lower false negative

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 Factors affecting predictive values
• The higher the prevalence, the more likely it is that
a positive test is predictive of the diseases i.e. PPV
will be high.
• The more specific the test, the less likely an
individual with a positive test will be to be free from
the disease and the greater the predictive value
positive.
• The more sensitive a test, the less likely it is that an
individual with a negative test will have the disease
and thus the greater the predictive value negative.
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 Prevalence of disease versus predictive values

o Predictive value positive is

directly related to the PV (+)

prevalence of a disease in a
community
Prevalence

o Predictive value negative is

inversely related to the
prevalence of a disease in a PV (-)

community
Prevalence
NB: If sensitivity and specificity are constant 42
 exercise
A new test was developed for screening of breast
cancer. This new test was applied on 750 women known
early cases of breast cancer and 900 women free from
Breast cancer on the gold standard test. The new test
was positive for 600 women with breast cancer and 60
women without breast cancer.

Construct a two-by-two table showing the above screening

test results and disease status
Calculate Sensitivity
Calculate Specificity
Calculate Positive predictive value
Calculate Negative predictive value
1/12/2023 43
 solution
• Gold standard result
• Total diseased=true positive + false negative
• =a+c=750
• c=750-a
• total dease free= false positive+ true negative
• =b+d=900
d=900-b Therefore,
C=750-600
• New test result
=150
• True positives=a=600 D=900-60
• False positive=b=60 =840
• Sensitivity = true positive *100 = 600*100=80%
true positive +false negative 750

specificity= true negative x100= 840 x100=~93%

true negative+false positive 900

CalculatePPV and NPV?????

 Reliability (Precision)
 Refer to the consistent of results when repeat
examination are performed on the same person under the same
conditions.
 Factors affect a reliability
I. biological variation
e.g. BP
II. variation in the test method
e.g. stability of the reagents
III. Observer variation
-intra observer variability
-inter observer variability

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 Intra-observer variation
 Is a variation in the result of a test due to the same
observer examining the result at different times
 The amount of variation one observer experiences when
observing the same material more than once

 The difference is due to the extent to which observer(s)

agree or disagree when interpreting the same test result

 Assessments of the same observer at different

times.

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 Inter-observer variation

• Is a variation in the result of a test due to

multiple observers examining the result.
• The amount of variation between the results
obtained by two or more observers examining
the same material.
• Assessments of different observers at the same time.

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 Method to reduced these variations

1. Careful standardization of procedures

2. An intensive training period for all observers or

professionals

3. Periodic checks on their work

4.The use of two or more observers making independent

observations.

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 Assessing reliability
1.Percent agreement=Percent agreement is
the proportion of all diagnoses classified the
same way by two observers.
A perfect agreement occurs when:b=0
c=0
Observer 1
positive negative

Obsever- positive a b
2
negative c d

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 Percent agreement

Overall Percent Agreement = (a+d) *100

a+b+c+d

Percent Positive Agreement = a *100

a+b+c

1/12/2023 51
 Yield
• The number of cases of the condition detected by
screening test in relation to the total number of persons
screened

• Yield=
Tp
 100%
Tn  Tp  Fn  Fp

• Affected by sensitivity, prevalence of unrecognized cases,

number of tests employed, frequency of screening and
participation of people in screening and follow-up

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Example..

DIAGNOSTIC TEST
SCREENING (Gold standard)
Test result + - total
+ 450 150 600
- 50 350 400
total 500 500 1000

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 Calculate
• Sensitivity
• Specificity
• Positive predictive value
• Negative predictive value
• Yield
• Negative percent agreement
• Positive percent agreement
• Percent aggreement

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 !!!

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