Screening tests

Dr Nashwa Radwan
Pro of Public Health and Preventive
Medicine
Radwan_n_m@hotmail.com
 Learning objectives
• Definition.
• Purpose.
• Types.
• Advantage.
• Disadvantage.
• Criteria of effective screening.
• Validity.
• Examples.
 Definition
• Screening is the initial examination of
an individual to detect disease not yet
under medical care. Screening may be
concerned with a single disease or with
many diseases( called multiphasic
screening).
 Purpose
to sort out apparently well person who
probably have the disease from those
who probably do not.
So, Screening separates apparently
healthy individuals into groups with
either a low or high probability of
developing the concerned disease.
 Types of screening

According to:
• The diseases concerned with
screening.
• Types of tests.
• People subjected to screening.
 Types of diseases
concerned with screening
• A-Acute communicable diseases
(rubella)
• B-Acute non-communicable disease
(lead toxicity)
• C-Chronic communicable disease (TB)
• D-Chronic non communicable disease
(glaucoma)
 Testing of patients
1-Case finding test.
To detect unrecognized disease (performed on
apparently healthy people).
2-Diagnostic testing
To determine or explain the etiology of disease
(performed on diseased patients)
3-Treatment testing
To evaluate the effectiveness of therapy of
recognized disease (performed on patients
received therapy)
 Types of people subjected to
screening

A- Selective screening
B-Mass screening
C-Opportunistic screening
 Selective screening -1
• It means screening a high risk group,
for example screening for bone
thickness among female at menopause,
chest x-ray for heavy smoker males
with chronic cough.
 Mass screening-2

• It is done to a large number of people

irrespective of their risk status, e.g.
screening for hypertension or diabetes
mellitus in a certain city
 Opportunistic screening-3

• It is applied when the opportunity

arises, as for example in pre-placement
examination. Examination of students
at school entry, soldiers who join the
army by general clinical examination,
urine and stool analysis, blood picture,
dental examination and visual acuity
 Advantages

• Magnitude of disease can be precisely

assessed, where pre-symptomatic
cases are not missed.
• Early detected cases can be effectively
controlled, with better prognosis, no or
minimal consequences and less
burden of health services
 Disadvantage

• It is not 100% accurate test. Detected

cases may be actually free of the
disease (called false positives). On the
other hand, the test may misdiagnose
actually diseased persons (false
negatives). The higher the percentages
of false positive and false negatives the
worse is the screening test.
Criteria for effective screening
Criteria of the disease concerned
by screening
1-Should be of a relatively public health
significance (high prevalence, high risk for
undiagnosed disease, serious complications,
affect vulnerable group)
2-The natural history of the disease should be
understood.
3-An acceptable treatment must be exist.
4-The undiagnosed disease should be more
amenable to control than symptomatic one.
 Criteria of test
1-It should be highly sensitive and
specific.
2-It should be applicable and acceptable
to a large number of individuals.
3-It should be simple e.g. accomplished
easily and quickly.
4-It should be harmless to the individuals
being tested.
5-It should be relatively inexpensive.
 Validity of screening tests

Definition:
• Validity of a test means the extent to
which a test measures what is
supposed to measure. The clinical
usefulness of the test is measured
through screening test parameters.
 Screening test parameters
• Sensitivity
• Specificity
• Positive predictive value
• Negative predictive value
 Gold standard
• In order to determine, the validity of a
screening test,( through measuring
screening test parameters) a fourfold
table is used in which the screening
test results are tabulated according to
the person true disease status, which
is generally determined by a gold
standard diagnostic test.
Screening True diagnosis Total
test (by gold standard)
Diseased Not-
diseased
Positive a b a+b
True positive False positive

Negative c d C+d
False negative True negative

Total a+c b+d N

• Sensitivity(%) =a/a+c100×
• Specificity(%) =d/b+d 100×
• Positive predictive value =a/a+b 100×
• Negative predictive value =d/c+d
×100
 Sensitivity
• Sensitivity is ability of the screening
test to identify correctly those
individuals who truly have the disease.
• Sensitivity usually is expressed as
percentage.
• Sensitivity is the ratio of individuals
with the disease whose screening test
is positive to the total number of
individuals with the disease.
 Specificity
Specificity is the test’s ability to identify
correctly those individuals who truly don’t
have the disease.
Specificity usually is expressed as a
percentage.
Specificity is the ratio of the number of
individuals without the disease whose
screening test are negative to the total
number of individuals without the disease
under the study..
 Positive predictive value
• The positive predictive value is the test’s ability to
identify those individuals who truly have the
disease (true positive) among those individuals
whose screening tests are positive.
• Positive predictive value usually is expressed as
ratio.
• The positive predictive value is the ratio of the
number of individuals with the disease whose
screening tests are positive to the total number
whose screening tests are positive.
• The predictive value of a positive test increases
with increasing disease prevalence. Therefore,
high risk populations are the best targets for
screening programs.
 Negative predictive value
• The negative predictive value is the test’s ability to
identify those individuals who truly don’t have the
disease (true negative) among all individuals
whose screening tests are negative.
• The negative predictive value usually is expressed
as percentage
• The negative predictive value is the ratio of the
number of individuals without the disease whose
screening tests are negative to the total number
whose screening tests are negative..
• The predictive value of a negative test decreases
with increasing disease prevalence.
Problems
 Example

• In a study to evaluate the validity of clinical

examination as a screening test to detect cancer
breast, 100 women were examined clinically and
by mammography (gold standard test) and the
results were tabulated in the following four
folded table.
Calculate:
• Sensitivity, specificity, positive and negative
predictive value.
• Evaluate the validity of clinical examination as a
screening test for cancer breast.
Clinical Mammography Total
examination
Positive Negative
Positive 15 30 45

Negative 10 45 55

Total 25 75 100
 Result
• Sensitivity = (15 / 25) × 100 = 60 %
• i.e. clinical examination diagnose only 60% of truly cancer cases (as
diagnosed by standard method).
• Specificity = ( 45 / 75 ) × 100 = 33.3 %
• i.e. clinical examination identify 33 % of the individuals who truly do
not have the disease as diagnosed by mammography (gold standard).
• Positive predictive value= (15/45 ) ×100 =33.3%
• i.e.33% from those who were diagnosed by clinical examination as
positive (have cancer breast), truly have the disease .
• Negative predictive value = ( 45 / 55 ) × 100 = 81.8 %
• i.e.82% of the individuals who were diagnosed as negative (do not
have cancer breast) by clinical examination, do not truly have the
disease (as diagnosed by mammography )
• Therefore, clinical examination screening test is not valuable because
of low sensitivity and specificity.
 Example

• A group of 150 individuals were

examined for diabetes by blood sugar
curve (gold standard test) and by
glucose in urine as a screening test.
The results are tabulated in the
following table. Is glucose in urine a
valid test for diagnosis of diabetes?
Why?
Urine Blood glucose curve Total
analysis
Diabetic Non-
diabetic
Diabetic 22 28 50

Non- 8 92 100
diabetic
Total 30 120 150
 Result

• Sensitivity = 22 / 30 × 100 = 73.3 %.

• Specificity = 92 / 120 × 100 = 76.6 %.
• Glucose in urine can be considered a valid test
because its sensitivity is 73% and specificity is 77%
(over 70 %). If there is another screening test for
diabetes whose sensitivity is more than 73% it will
be more valid than glucose in urine testing.
• Choosing a screening test is not easy. It needs trial
of many tests for diagnosis and the test that gives
the highest sensitivity and specificity will be the
best.
•
 Example
• A new screening method for measuring
diastolic blood pressure is compared to the
standard method (sphygmomanometry)in a
trial with 300 members of a community
center. Of the 45 persons with known
hypertension, 36 have hypertension detected
by the new method, of the 255 persons
without diastolic hypertension, 230 have
normal blood pressure by the new method.
• Calculate: sensitivity, specificity, PPV and
NPV
New Sphygmomanometery Total
method
Yes No
Positive 36 25 61

Negative 9 230 239

Total 45 255 300

 Result
• Sensitivity = 36/45 or 80%
• The new screening method detect hypertension
among 80% of those truly have hypertension
• i.e. 80% of those truly have hypertension were
correctly identified by the new screening method
• Specificity= 230/255 or 90%.
• i.e. 90% of individuals who do not have hypertension
were correctly identified by the new
screening method.
• PPV=36/61or 59%
• NPV=230/239 or 96%