INTRODUCTION

An understanding of health is the basis of

all health care .Health has evolved over the
centuries as a concept from an individual concern
to a worldwide social goal and encompasses the
whole quality of life.
Quick look
 Health
 Disease
 Iceberg of disease
 Concepts of control
 Concepts of prevention
 Levels of prevention
 Screening
Health
WHO definition
“Health is a state of complete physical, mental
and social well-being and not merely an absence of
disease or infirmity”
Disease
 The term “disease” literally means – “without
ease”
 No definition till date but distinction has been
made between the words disease, illness and
sickness
 By Susser

Disease Sickness

physiological/psychological state of social dysfunction

dysfunction

Illness

subjective state of the person who feels aware of

not being well
Iceberg of Disease
According to this concept, disease in a
community may be compared with an
iceberg.
Concepts of Control

Disease control aims at reducing :

 Incidence of disease
 Duration of disease
 Risk of transmission
 Effects of infection
 Financial burden to community
Concepts of Prevention

The goals of medicine are to promote health ,to

preserve health, to restore health when it is impaired
and to minimise suffering and distress.
These are embodied in the word “prevention”
Levels of prevention

Four levels
• Primordial prevention
• Primary prevention
• Secondary prevention
• Tertiary prevention
Primordial prevention

It is the prevention of the emergence of risk factors

in countries or population groups in which they have
not yet appeared.
Includes
Individual and mass education
Primary prevention

Defined as “action taken prior to the onset of disease

which removes the possibility that a disease will ever
occur”
Includes
Population strategy and high risk strategy
Secondary prevention

Defined as “action which halts the progress of a

disease at its incipient stage and prevents
complications”
Includes
Early diagnosis - screening test, case finding
Adequate treatment
Tertiary prevention

Defined as all measures available to reduce or limit

impairments and disabilities, minimise suffering
caused by existing departures from good health and
to promote the patients adjustment to irremediable
conditions.
Includes
Disability limitation
Rehabilitation
SCREENING
SCREENING

Defined as
“The search for unrecognized disease or
defect by means of rapidly applied tests, examinations
or other procedures in apparently healthy
individuals”
Screening Vs periodic health
examinations
Capable of wide application

Relatively inexpensive

Requires less physician time

 Screening test
Done on apparently healthy
Applied to groups
Test results are arbitrary and final
Diagnostic test
Done on those with indications or
sick
Applied to single patients,all diseases
are considered
Diagnosis is the sum of all evidence

Based on one criterion or cut-off Based on evaluation of a number of

point symptoms, signs and lab findings
Less accurate More accurate

Less expensive More expensive

Not a basis for treatment Used as a basis for treatment

Initiative by investigator or agency Initiative from patient with complaint

providing care
Concept of lead time
 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
 Earlier diagnosis
 Treatment of diseased
 Alter the natural history of disease
Possible outcomes of screening

Apparently healthy

Apparently normal Apparently abnormal

a)Normal-periodic screening

b)Intermediate - surveillance

c)Abnormal- treatment
Explanation of terms
 Screening
 Case finding
 Diagnostic tests
 Screening
◦ Strictly speaking, screening is testing for
infection or disease in populations or in
individuals who are not seeking health care
◦ For example:
 Serological testing for AIDS virus in blood donors
 Neonatal screening
 Premarital screening for syphilis
 Case finding
◦ Use of clinical and/or laboratory tests to
detect disease in individuals seeking health
care for other reasons
◦ For example:
 Use of VDRL test to detect syphilis in pregnant
women
 Diagnostic tests
◦ Use of clinical and/or laboratory procedures
to confirm or refute the existence of disease
or true abnormality in patients with signs and
symptoms presumed to be caused by the
disease
◦ For example:
 Endocervical culture for N.gonorrhea
Uses of screening
 Case detection
 Control of disease
 Research purpose
 Educational oppurtunities
Types of screening

 3 types
a. Mass screening
b. High risk or selective screening
c. Multiphasic screening
Mass screening
 Simply means screening of a whole
population or a subgroup
 Example : all adults
 Mass screening should always be backed
up by suitable treatment
High risk or selective screening
 Most effective if applied selectively to high
risk groups, the groups defined on the
basis of epidemiological research
 Ex: screening for cancer cervix in the
lower social groups
 Screening for diabetes, hypertension,
breast cancer among family members and
relatives
 Screening for risk factors
Multiphasic Screening
 Defined as the application of two or more
screening tests in combination to a large
number of people at one time than to
carry out separate screening tests for
single diseases.
 May include
 Health questionnaire
 Clinical examinations
 Range of measurements and investigations
 Blood and urine tests
 Lung function assessment
 Measurement of visual acuity
Drawback of multiphasic screening
 Tests have not been validated
 No benefits regarding mortality and
morbidity reduction
Criteria for screening
 Worthwhile
 Ethical justification
 Scientific justification
 Financial justification
Considerations
Disease
Screening test
Disease
Should fulfil the following criteria
1. Important health problem
2. Recognizable latent or early
asymptomatic stage
3. Natural history of the condition
4. A test which can detect the disease
prior to the onset of signs and
symptoms
5. Facilities should be available for
confirmation of the diagnosis
6. There is an effective treatment
7. Agreed on policy concerning whom to
treat as patients
8. Good evidence that early detection and
treatment reduces morbidity and mortality
9. Expected benefits exceed the risks and
costs
Screening test
 Must satisfy
Acceptability
Repeatability
Validity
Also
 Yield
 Simplicity
 Safety
 Rapidity
 Ease of examination
 cost
Acceptability
 Must not be
 painful
 Discomforting
 Embarassing

Ex
Rectal or vaginal examinations in mass
campaigns
Repeatability
 Must give consistent results when
repeated more than once on the same
individual or material under the same
conditions.
 Depends on
 Observer variation
 Biological variation
 Errors relating to technical methods
Observer variation
 Two types
a) Intra-observer variation
b) Inter-observer variation
Intraobserver variation
 Also called as within observer variation
 Variation between repeated observations
by same observer on same subject or
material at the same time
 Minimized by taking average of the
measurements
Interobserver variation
 Also called as between observer variation
 Variation between different observers
Biological variation
 It is also called as subject variation
 Associated with many physiological
variables such as
◦ Blood pressure
◦ Blood sugar
◦ Serum cholesterol etc
Due to
A. Changes in the parameters observed
Ex: MI with or without pain

B. Variation in the way patients percieve

their symptoms and answer
Ex: recollection of past events

C. Regression to the mean

Ex : blood glucose in diabetes,
stool frequency in ulcerative colitis
Errors due to technical methods
 Ex
 Defective instruments
 Erroneous calibration
 Faulty reagents
 Test itself
Validity
 Term validity refers to what extent the
test accurately measures which it
purports to measure
 Ability of a test to separate or distinguish
those who have the disease from those
who do not.
 Diabetes screening test –glycosuria
Accurate test – glucose tolerance test
 Validity has two components
1. Sensitivity
2. Specificity
 Both are expressed in %
Evaluation of a screening test
 The following measures are used to
evaluate a screening test
1. Sensitivity
2. Specificity
3. Predictive value of a +test
4. Predicitive value of a – test
5. % of false negatives
6. % of false positives
 Disease

True positives False positives

a b
Test
False negatives True negatives

c d
Sensitivity
 Term introduced by Yerushalmy
 Defined as the ability of a test to idenitify
all those who have the disease
 “true positives”
 Ex: 90% sensitivity means
 90 % of diseased people show true
positive
 10 % of give false negative result
 Disease

True positives False positives

a b
Test
False negatives True negatives

c d
Specificity
 Defined as the ability of a test to identify
correctly those who do not have the
disease
 “true negatives”
 Ex: 90% specificity means
 90 % of non diseased give true negative
result
 10% of non diseased give false positive
result
 Disease

True positives False positives

a b
Test
False negatives True negatives

c d
Predictive accuracy
 Measures the diagnostic power of the test
 Depends on sensitivity ,specificity and
disease prevalence
 Predictive value of a positive test indicates
that a patient with a positive test result
has in fact the disease in question
 More prevalent the disease in a
population more will be the predictive
value of a positive test
 Disease

True positives False positives

a b
Test
False negatives True negatives

c d
False negatives
 Means that patients who actually have the
disease are told that they do not have the
disease
 Giving them a false reassurance
 A screening test which is very sensitive
has very few false negatives
 Disease

True positives False positives

a b
Test
False negatives True negatives

c d
False positive
 Means that patients who do not have the
disease are told that they have the disease
 A test with high specificity will have few
false positives
 Disease

True positives False positives

a b
Test
False negatives True negatives

c d
Yield
 Yield is the amount of previously
unrecognized disease that is diagnosed as
a result of the screening effort
 Depends upon
 Sensitivity
 Specificity
 Prevalence of disease
 Participation of individuals
 High risk individuals are selected
Combination of tests
 Two or more tests can be used in
combination to enhance the specificity or
sensitivity of screening
 Ex
 Syphilis
 First RPR test yield false positives
 Positives submitted to FTA-ABS more
specific
Boderline cases
Evaluation of screening programmes
 Screening programmes should be
introduced only after proper evaluation
1. Randomized control trials
2. Uncontrolled trials
3. Other methods
 RCT
◦ Ideally should be performed where in the
setting where the screening programme will
be implemented and should employ the same
type of personnel,equipment and procedures
that be used in that programme.
 Uncontrolled trials
◦ Used to see if people with the disease
detected through screening appear to live
longer after diagnosis and treatment than
patients who were not screened
◦ For ex: cervical cancer screening reduced the
number of deaths
 Fogorv Sz. 2003 Oct;96(5):193-6.
 [Stomato-oncological screening in diabetic patients].
 [Article in Hungarian]
 Ujpál M1, Matos O, Bíbok G, Somogyi A, Suba Z.
 Author information
 1Semmelweis Egyetem Szájsebészeti és Fogászati Klinika.

 Abstract
 The data of the literature suggest that studies have not been performed to date on
possible correlations between diabetes and precancerous states and tumors in the oral
cavity. Internationally, only one investigation appears to have dealt with the incidence of
leukoplakia among diabetics. In the present work, stomato-oncological screening was
performed on 200 treated diabetics. Precancerous lesions were found in 8%, and benign
lesions in 14.5%. Comparison with earlier Hungarian screening studies indicated that
benign and precancerous lesions occur with greater frequency among diabetics than in the
average population.The proportion of oral cavity lesions is higher among diabetics of type
2 than among those of type 1. The combination of diabetes mellitus and smoking means an
enhanced risk from the aspect of precancerosis of the oral cavity.
 PMID: 14635491
 [PubMed - indexed for MEDLINE]
Conclusion
The screening concept filled with
potential has been overburdened with
problems, many of which remain unsolved.
Regardless of the approach taken to
screening tests, regular follow-up visits are
important if effective health and medical
care are to result from the effort.
References
 Park’s textbook of preventive and social
medicine -22nd edition