Download Screening for - Gundersen Health Plan

Adult Preventive Care Guidelines
2013 - 2014
For Professionals and Healthcare Providers
1
Revised January 2014
Table of Contents
Adult Preventive Care Timeline.................................................................................................................................... 3
Periodic Health Examination (PHE) ........................................................................................................................... 4
Height, Weight and Body Composition Assessment ................................................................................................ 5
SCREENING TESTS ................................................................................................................................................... 6
Screening for Hypertension .............................................................................................................. 6
Screening for Lipid Disorders .......................................................................................................... 9
Screening for Diabetes Mellitus ...................................................................................................... 11
Screening for Breast Cancer ............................................................................................................ 14
Screening for Cervical Cancer ......................................................................................................... 16
Screening for Chlamydia ................................................................................................................. 18
Screening for Colorectal Cancer ...................................................................................................... 19
Screening for Impaired Vision......................................................................................................... 21
Screening for Osteoporosis ............................................................................................................. 23
COUNSELING ............................................................................................................................................................ 28
Counseling for Prostate Cancer Screening ..................................................................................... 28
Tobacco Use and Dependence – Identification, Assessment and Treatment ............................... 31
Obesity Assessment and Counseling ............................................................................................. 33
Alcohol and Other Substance Abuse Counseling .......................................................................... 35
Assessment and Counseling for Depression .................................................................................. 36
Injury Prevention Counseling......................................................................................................... 38
Sexual Behavior Assessment and Counseling ................................................................................ 40
IMMUNIZATIONS .................................................................................................................................................... 41
Tetanus, Diphtheria and Pertussis .................................................................................................. 41
Influenza ......................................................................................................................................... 43
Pneumococcal Pneumonia ............................................................................................................. 45
Herpes Zoster ................................................................................................................................. 47
Human Papillomavirus................................................................................................................... 48
Meningococcal Meningitis ............................................................................................................. 50
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Revised January 2014
Adult Preventive Care Timeline
Age 18-19
Periodic Health
Examination (PHE)
Height
Weight
20
21-25
30-34
26-29
35-39
40-44
45-49
50-54
Every 3-5 years
55-59
60-64
75+
Every 1-2 years
Screening Tests
Chlamydia
Yearly
Pap Smear Every 3
years
Blood Pressure measurement at least every 2 years
Fasting Total Lipid Profile every 5 years
Fasting Blood Sugar every 3 years for BMI > 25.0
Mammography and Clinical Breast Exam Yearly
Pap Smear Every 3 years; OR
Pap Smear and HPV Test Every 5 years
Colonoscopy every 10 years OR Stool specimen
yearly (Sigmoidoscopy every 5 years is acceptable)
Colorectal Cancer
Impaired Vision
Eye Exam every 2-4 years
Eye Exam every 1-2 years
Bone Mineral Density At
least once
Osteoporosis
Counseling
Counseling on Prostate
Cancer Screening
Counseling on Tobacco
Use, Obesity – Diet and
Exercise, Alcohol and
Other Substance Use,
Depression, Injury
Prevention, Sexual
Behavior
Applies to
70-74
At least once
At each PHE
Hypertension
Lipid Disorder
Diabetes
Breast Cancer
Cervical Cancer
Tetanus-Diphtheria
Pertussis
Influenza
Pneumococcal
Herpes Zoster
Human Papilloma Virus
Meningococcal
65-69
Counsel at each PHE
Counsel at each PHE
Immunizations
Tdap once, then Td every 10 years
Yearly
One or two doses in high risk groups
3 doses
Once in high risk groups
Females
Males
Both
3
Once
Once
Adult Preventive Care Guidelines – 2013-2014
Periodic Health Examination (PHE)
Recommendation:
Adults between the ages of 18 and 39 should have a complete exam every 3 to 5 years. These exams
should be increased to every 1 to 2 years at age 40. Exams should be coordinated and tailored to
cover all the basic preventive exams, counseling and immunizations based on the patient’s age,
gender and specific health condition.
Basis for the recommendation:
The periodic health examination (PHE) is an important opportunity for the delivery of clinical
preventive services. Although preventive services can serve as the basis for designing periodic
checkups devoted entirely to disease prevention, preventive services may also be performed during
visits for other reasons (e.g., illness visits, chronic disease checkups) when indicated. For patients
with limited access to care, the illness visit may provide the only realistic opportunity for the
clinician to discuss prevention. It is recognized that busy clinicians may not be able to perform all
recommended preventive services during a single clinical encounter. Patients suffering from an acute
illness or injury may not be receptive to some preventive interventions.
The clinician must therefore use discretion in selecting appropriate preventive services from these
recommendations, and may wish to give special emphasis to those preventive services aimed at the
leading causes of illness and disability for the patient’s age group. In 2007, (the most recent year this
was available) the leading causes of preventable deaths in the Midwest were:
For someone less than 25: 1) motor vehicle or other unintentional injuries, 2) homicide, 3)
suicide, 4) malignant neoplasms, and 5) heart disease.
For adults ages 25 to 44, the leading causes of death were: 1) motor vehicle or other
unintentional injuries, 2) malignant neoplasms, 3) heart disease, 4) suicide, and 5) homicide
For adults ages 45 to 64, the leading causes of death were: 1) malignant neoplasms, 2) heart
disease, 3) motor vehicle or other unintentional injuries, 4) chronic lower respiratory disease, and
5) diabetes mellitus.
For adults age 65 and older, the leading causes of death were: 1) heart disease, 2) malignant
neoplasms, 3) cerebrovascular disease, 4) chronic lower respiratory disease, and 5) Alzheimer’s
disease.1
References cited:
1. Centers for Disease Control and Prevention. WISQARS Leading Causes of Death Reports, 1999
– 2007, Available at http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html accessed on
5/17/2013.
4
Height, Weight and Body Composition Assessment
Recommendation:
The height and weight of all adults should be routinely measured and evaluated. At least once over
age 18, an accurate height should be measured and recorded with other retrievable vital signs, so this
measure can be easily accessed later by other clinicians. A weight should be measured at each visit,
or at least during periodic health examinations and also recorded. A body mass index (BMI, body
weight in kilograms divided by the square of height in meters) above 30 in both men and women
should be used as a basis for further intervention and counseling for obesity. See Obesity Assessment
and Counseling below for more information.
The optimal frequency for measuring height and weight in adults is a matter of clinical discretion.
The U.S. Preventive Services Task Force found sufficient evidence to recommend screening all adult
patients for obesity with a body mass index calculation, but they left the frequency of this screening
up to the clinician. They further conclude that the benefits of screening outweigh any potential
harm.1 The Canadian Task Force on Preventive Health Care found insufficient evidence to
recommend for or against BMI measurement in the periodic health examination of the general
population.2 The American Academy of Family Physicians3 and the American College of Preventive
Medicine recommends periodic BMI measurement of all adults.4 The American Heart Association
recommends a body weight measurement every five years.5
References cited:
1. U.S. Preventive Services Task Force. Screening for obesity in adults. Ann Intern Med
2003;139(11):930-2.
2. Douketis JD, Feightner JW, Attia J, Feldman WF. Periodic health examination, 1999 update: 1.
Detection, prevention and treatment of obesity. Canadian Task Force on Preventive Health Care.
CMAJ 1999;160(4):513-25. Available at www.cmaj.ca/cgi/reprint/160/4/513.pdf. Accessed
3/16/2011.
3. American Academy of Family Physicians. Periodic Health Examinations. Recommend: General
Population. Revision 5.3, August 2002. Available at
http://www.aafp.org/online/en/home/clinical/exam/obesity.html accessed 3/16/2011
4. Nawaz H, Katz D. American College of Preventive Medicine Medical Practice Policy Statement:
Weight Management Counseling for Overweight Adults. Am J Prev Med 2001;21:73-8.
5. Grundy SM, Greenland P, Herd A, et al. Cardiovascular and risk factor evaluation of healthy
American adults. A statement for physicians by an ad hoc committee appointed by the Steering
Committee, American Heart Association. Circulation 1987; 75:1340A-1362A.
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Revised January 2014
SCREENING TESTS
Screening for Hypertension
Recommendation:
Gundersen recommends a blood pressure measurement for all adults, beginning at age 18, at least
once every two years, but optimally at each visit with a clinician.
Sphygmomanometry is to be performed in accordance with recommended techniques. Hypertension
should not be diagnosed on the basis of a single measurement; elevated readings should be the
average of two or more properly measured, seated BP reading on each of two or more visits.1
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7)3 changed the classification of blood pressure. Only
patients with a BP of <120/80 mmHg are considered to be normotensive; any adult with a BP
>120/80 mmHg has a greater risk to develop cardiovascular disease (CVD) and should be screened
more frequently, at least yearly but varying by level.
Disease and basis for recommendation:
Coronary heart disease (CHD) is the leading cause of morbidity and mortality in the United States.
In 2009, CHD attributed to 386,324 deaths (16% of all deaths) and an associated morbidity cost
greater than $312.6 billion annually, in this country alone.1 Every year, over 635,000 Americans will
suffer a new coronary attack and an addition 280,000 will have a recurrent attack. 1 In the last 30
years, numerous clinical and epidemiological studies have established a solid link between elevated
blood pressure levels and an increased risk for developing CHD.2
Hypertension (high blood pressure) affects 78 million Americans and, in 2009, it was the primary
cause of death for nearly 24,000 of them.2-4 One in three adults have hypertension and of those, 18%
do not know that they have it.5-6 Data from the Framingham Heart Study suggests that persons who
are normotensive at age 55 have a 90% life-time risk for developing hypertension.7 Thus, as the
population continues to age, the prevalence of hypertension will increase.
The relationship between BP and risk of CVD event is continuous, consistent, and independent of
other risk factors. The higher the BP, the greater the risk of heart attack, stroke, heart failure, and
kidney disease. In persons aged 40-70 years, each increment of 20 mmHg in systolic blood pressure
(SBP) or 10 mmHg in diastolic blood pressure (DBP) doubles the risk of CVD across the entire BP
range from 115/75 to 185/115 mmHg.2
There are several risk factors for the development of hypertension besides increasing age. These
include: family history, gender, lack of physical activity, poor diet (especially one that includes too
much salt), overweight and obesity, and alcohol abuse. Possible contributing factors include excess
stress, smoking and regular exposure to second-hand smoke, and sleep apnea.8
All patients should be encouraged to make lifestyle modifications (i.e. weight reduction, decrease in
sodium intake, increase in physical activity, adoption of DASH eating plan, and moderation of
alcohol consumption).3 Clinicians should note that BP control rates are lower in all minority groups;
Mexican Americans and Native Americans are lowest.3 In general, treatment for hypertension is
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Revised January 2014
similar for all demographic groups, but socioeconomic factors and lifestyle may be barriers to BP
control in some patients.
The most important key message from the JNC-7 is the classification of blood pressure for adults:3
INITIAL DRUG
THERAPY
BP Classification
SBP
mmHgi
DBP
mmHgi
Lifestyle
Modification
NORMAL
<120
and <80
ENCOURAGE
PREHYPERTENSION
120-139
or 80-89
YES
STAGE 1
HYPERTENSION
140-159
or 90-99
YES
STAGE 2
HYPERTENSION
>160
or >100
YES
Without
Compelling
Indication
With
Compelling
Indications
No antihypertensive
drug indicated.
Thiazide-type
diuretics for
most.iii
Drug(s) for
compelling
indications.ii
Drug(s) for
compelling
indications.ii
Other antihypertensive
drugs as
needed.
Two-drug
combination
for most.iv
iTreatment
determined by highest BP category.
patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
iiiMay consider angiotensin converting enzyme inhibitor, angiotensin receptor blocker, beta blocker, calcium channel
blocker, or combination.
ivInitial combined therapy should be used cautiously in those at risk for orthostatic hypertension.
iiTreat
Other Organizations’ Recommendations:
The U.S. Preventive Services Task Force recommends that blood pressure should be measured
regularly in all adults aged 18 and older.9 While they there was insufficient evidence to state a
beneficial screening interval, the referenced the JNC-7’s recommendations of at least every two
years, as a reasonable screening frequency.3 Similar guidelines by the American Heart Association
(AHA) have recommended screening for all adults beginning at age 20 years.10
Most organizations such as the American Academy of Family Physicians,11 refer to the JNC-7
recommendations as the standard. The Canadian Task Force recommends measuring a blood
pressure on all adults 18 years and older at every primary care visit.12
In 2012, the NHLBI convened three expert panels to update the existing guidelines on high blood
cholesterol, high blood pressure, and obesity. In addition, three work groups were convened to
examine cross-cutting issues: lifestyle interventions, risk assessment, and guidelines implementation.
These guidelines will be released in 2013.13
7
Revised January 2014
References cited:
1. American Heart Association Statistics Committee and Stroke Statistics Committee. Heart Disease
and Stroke Statistics—2013 Update. A Report from the American Heart Association. Circulation.
2013;127:e6-e245.
2. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to
vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies.
Lancet. 2002;360:1903-13.
3. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The
seventh report of the Joint National Committee on Detection, Evaluation, and Treatment of High
Blood Pressure. Hytertension. 2003;42: 1206-1252.
4. Centers for Disease Control and Prevention. Vital and health statistics Summary Health Statistics
for U.S. Adults: National Health Interview Survey, 2009. August 2010. Available at:
http://www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf Accessed on 3/2/11
5. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/fastats/hyprtens.htm
Accessed on 3/2/11
6. Ostchega Y, Yoon SS, Hughes J, Louis T. Hypertension awareness, treatment, and control -continued disparities in adults: United States, 2005–2006. NCHS data brief no Hyattsville, MD:
National Center for Health Statistics. 2008.
7. Vasan RS, Beiser A, Seshardi S, et al. Residual lifetime risk for developing hypertension in middleaged women and men: The Framingham Heart Study. JAMA. 2002;287:1003-10.
8. American Heart Association. Understand your risk for high blood pressure. Available at:
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHig
hBloodPressure/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp
Accessed on 3/2/11.
9. U.S. Preventive Services Task Force. Screening for high blood pressure: U.S. Preventive Services
Task Force recommendation statement. Ann Intern Med 2007:147-783-786..
10. Pearson TA, Blair SN, Daniels SR, et al. AHA Guidelines for Primary Prevention of
Cardiovascular Disease and Stroke: 2002 Update. Circulation. 2002;106:388-91.
11. American Academy of Family Physicians. Adult hypertension screening guidelines. Available at:
http://www.aafp.org/online/en/home/clinical/exam/hypertension.html
Accessed on 3/21/13
12. Canadian Task Force on Preventive Health Care. Recommendations on screening for high blood
pressure in Canadian Adults, 2012. http://canadiantaskforce.ca/guidelines/screening-forhypertension/
Accessed on 3/21/13
13. National Heart, Lung, and Blood Institute. Cardiovascular Disease Risk Reduction in Adults.
Blood Pressure in Adults: Report from the Joint National Committee (JNC 8)
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc8/index.htm Accessed on 3/21/13
Approved on 4/5/13
8
Revised January 2014
Screening for Lipid Disorders
Recommendation:
For all adults aged 20 years or older, a fasting lipoprotein profile* (total cholesterol, high-density
lipoprotein [HDL], low-density lipoprotein [LDL], and triglycerides) should be obtained every five
years. The LDL level, classified according to the Adult Treatment Panel III (ATP III) guidelines, is
then used in conjunction with the patient’s addition risk factors to calculate the estimated 10-year
coronary heart disease (CHD) risk and accordingly, to determine the intensity of risk-reduction
therapy.
Despite national organizations’ recommendations to begin screening for lipid disorders in males
starting at age 35 and women starting at age 45, Gundersen recommends screening all adults at age
20. National recommendations indicate screening at an earlier age for those who are at increased risk
for coronary heart disease (who have one or more of the following risk factors: diabetes, tobacco
use, hypertension, obesity, a family history of cardiovascular disease before age 50 in male relatives
or age 60 in female relatives, or a previous personal history of heart disease.) Given the high
prevalence of risk factors in the Gundersen service area (>7% with diabetes, 20% tobacco use, 33%
hypertension, 42% obese) the recommendations are to screen all adults beginning at age 20.
*
NOTE: If the patient was in a non-fasting state when the test was performed, only the values for the total cholesterol
and HDL are useable. If the total cholesterol level is >200 mg/dL or the HDL is <40 mg/dL, a follow-up fasting
lipoprotein profile is needed to determine the LDL level for proper clinical assessment and management.
Disease and basis for recommendation:
Coronary heart disease (CHD) is the leading cause of morbidity and mortality in the United States.
In 2009, CHD attributed to 386,324 deaths (16% of all deaths) and an associated morbidity cost
greater than $312.6 billion annually, in this country alone.1 Every year, over 635,000 Americans will
suffer a new coronary attack and an addition 280,000 will have a recurrent attack. 1 In the last 30
years, numerous clinical and epidemiological studies have established a solid link between elevated
blood cholesterol levels and an increased risk for developing CHD.2
Animal studies, laboratory findings, epidemiological research, and genetic studies of familial
hypercholesterolemia have indicated that an increased level of LDL cholesterol is a major cause of
CHD.3 In population studies, the serum total cholesterol level has been found to be an accurate
alternative for LDL cholesterol levels. An estimated 13.8% or nearly 32 million adults 20 years of
age and older have a total serum cholesterol level > 240 mg/dL. Any level of LDL cholesterol above
100 mg/dL seems to be atherogenic. The Framingham Heart Study,4 the Multiple Risk Factor
Intervention Trial (MRFIT),5 and the Lipids Research Clinics (LRC) trial6 found a direct relationship
between levels of LDL cholesterol (or total cholesterol) and the rate of new-onset CHD in men. In
addition, recent clinical trials show that LDL-lowering therapy reduces the risk for CHD.3
For these reasons, the National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel
III) has continued to identify elevated LDL cholesterol as the primary target of cholesterol-lowering
therapy.3 Once the LDL cholesterol level has been determined, clinicians should assess the patient’s
CHD risk equivalent (i.e. the presence of atherosclerotic disease which confers high risk for CHD
events): clinical CHD, symptomatic carotid artery disease, peripheral arterial disease, abdominal
aortic aneurysm, or diabetes (NOTE: in ATP III diabetes is regarded as a CHD risk equivalent
9
Revised January 2014
rather than a risk factor.) Additionally, the clinician should determine the presence of major risk
factors (other than LDL): age (men > 45 years; women > 55 years), family history of premature
CHD (CHD in male first degree relative < 55 years; CHD in female first degree relative < 65 years),
hypertension (BP > 140/90 mmHg or use of antihypertensive medication), low HDL cholesterol (<
40 mg/dL; NOTE: HDL > 60 mg/dL counts as a “negative” risk factor; its presence removes one
risk factor from the total count), or current tobacco use. After ascertaining the above information,
the clinician can assess the patient’s short-term (10-year) CHD risk and determine if therapeutic
initiation is needed.
Other Organizations’ Recommendations:
The US Preventive Services Task Force released a statement in June of 2008 recommending periodic
measurement of total serum cholesterol and high-density lipoprotein cholesterol (HDL-C) using
specimens from fasting or nonfasting individuals for all men ages 35 and over and women ages 45
and over.7 They also recommend screening men 20-34, and women 20-44, who are at increased risk
for coronary heart disease (who have one or more of the following risk factors: diabetes, tobacco
use, hypertension, obesity, a family history of cardiovascular disease before age 50 in male relatives
or age 60 in female relatives, or a previous personal history of heart disease.) They made no
recommendation for or against screening men 20-34 years of age and women 20-44 years of age
who are not at increased risk for coronary heart disease (a C recommendation). The optimal
frequency for cholesterol measurement in asymptomatic persons was not determined based on
scientific evidence collected by the Task Force; however they suggest every 5 years unless therapy
warrants more frequent evaluation, or longer intervals for those with repeatedly normal levels. The
American Academy of Family Physicians and Institute for Clinical Systems Improvement follows
the recommendations of the US Preventive Services Task Force.8-9
Given the high prevalence of risk factors (7% with diabetes, 20% tobacco use, 33% hypertension,
42% obese) in the Gundersen service area the recommendations are to screen all adults beginning at
age 20.
In 2012, the NHLBI convened three expert panels to update the existing guidelines on high blood
cholesterol, high blood pressure, and obesity. In addition, three work groups were convened to
examine cross-cutting issues: lifestyle interventions, risk assessment, and guidelines implementation.
These guidelines will be released in 2013.10
References cited:
1. American Heart Association Statistics Committee and Stroke Statistics Committee. Heart Disease
and Stroke Statistics—2013 Update. A Report from the American Heart Association. Circulation.
2013;127:e6-e245.
2. Levine GN, Keaney JF Jr., Vita JA. Cholesterol reduction in cardiovascular reduction. Clinical
benefits and possible mechanisms. N Engl J Med 1995; 332:512-21.
3. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel
III) Final Report. Circulation. 2002;106:3143,-3421.
4. Wilson PWF, D’Agostino RB, Levy D, Belanger AM, et al. Prediction of coronary heart disease
using risk factor categories. Circulation. 1998;97:1837-47.
5. Stamler J, Wentworth D, Neaton JD, for the MRFIT Research Group. Is relationship between
serum cholesterol and risk of premature death from coronary heart disease continuous and graded?
10
Revised January 2014
Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT).
JAMA. 1986;256:2823-28.
6. Lipids Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial
results, I: Reduction in the incidence or coronary heart disease. JAMA. 1984;251:365-74.
7. US Preventive Services Task Force. Screening for lipid disorders in adults: US Preventive Services
Task Force Recommendation Statement. AHRQ Publication No. 08-05114-EF-2, June 2008
Agency for Healthcare Research and Quality, Rockville, MD. Available at:
http://www.ahrq.gov/clinic/uspstf08/lipid/lipidrs.htm. Accessed on 3/21/13.
8. American Academy of Family Physicians. Lipid disorders, adults. Available at:
http://www.aafp.org/online/en/home/clinical/exam/lipiddisorders.html Accessed on 3/21/13.
9. Institute for Clinical Systems Improvement. Preventive Services for Adults. Eighteenth
Edition/September 2012. Available at www.icsi.org Accessed on 3/21/13.
10. National Heart, Lung, and Blood Institute. Cardiovascular Disease Risk Reduction in Adults.
http://www.nhlbi.nih.gov/guidelines/indevelop.htm#status. Accessed on 3/21/13
Approved 5/2/13
Screening for Diabetes Mellitus
Recommendation:
Screening for diabetes with a fasting blood sugar (FBS), hemoglobin A1C (A1C), or 2-hour 75-g oral
glucose tolerance test (OGTT) as part of routine medical care should be considered at 3-year
intervals for all adults of any age who are overweight or obese (BMI > 25 kg/m2) and have one or
more of the following risk factors:
•
•
•
•
•
•
•
•
•
•
Sedentary lifestyle
Prior history of pre-diabetes/glucose intolerance
Race/ethnicity (e.g., African-Americans, Hispanic-Americans, Native Americans, AsianAmericans and Pacific Islanders)
Family history of diabetes in one or more first degree relatives
History of hypertension systolic of less than 140
History of vascular disease
History of dyslipidemia: HDL ≤ 35mg/dL and/or a triglyceride level ≥ 250 mg/dL
Markers of insulin resistance: (e.g., acanthosis nigricans and/or waist circumference > 40
inches in men and > 33.5 inches in women)
History of polycystic ovary syndrome (PCOS)
History of gestational diabetes mellitus (GDM) in women or deliver of a baby weighing
more than nine pounds at birth.
Due to the high prevalence of these risk factors in our population, most adults with a BMI > 25
kg/m2 should therefore be screened at least every 3 years.
In the absence of these risk factors, screening with a FBS should be done every 3 years beginning at
age 45 years.
These are new recommendations based on new evidence presented to the American Diabetes
Association's multidisciplinary Professional Practice Committee in 2010 and published in 2011.1
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Revised January 2014
Disease and basis for recommendation:
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from
defects in insulin secretion, insulin action, or both.1 The chronic hyperglycemia of diabetes causes
both macrovascular and microvascular damage of multiple organs, including the heart, kidneys, eyes,
nerves, and blood vessels. Glycation of tissue proteins and additional macromolecules and the
excess production of polyol compounds from glucose are the mechanisms thought to produce tissue
damage from chronic hyperglycemia.1 Patients with diabetes have an increased incidence of
atherosclerotic cardiovascular, peripheral vascular and cerebrovascular disease. Symptoms of
diabetes include polyuria, polydipsia, and polyphagia.
The prevalence of diabetes in 2010 was 8.3% of the US population, affecting over 25.8 million
people. The CDC estimates that 18.8 million people have been diagnosed and an additional 27%
have not been diagnosed in the United States. Diabetes was the seventh leading cause of death in
2007 in the US with over 71,000 adults dying from diabetes alone.2 The estimated cost of diabetes in
2007 was $174 billion in direct ($116 billion) and indirect ($58 billion) costs.2 Patients with
undiagnosed type 2 diabetes are at significantly increased risk of coronary heart disease, stroke and
peripheral vascular disease. Early detection and treatment are very important. Undiagnosed type 2
diabetes is common in the U.S. There is epidemiological evidence that retinopathy begins to develop
at least 7 years before clinical diagnosis of type 2 diabetes.3
Risk factors for diabetes include: 1) age > 45 years, 2) overweight (BMI > 25 kg/m2), 3) family
history of diabetes in parents or siblings, 4) habitual physical inactivity, 5) race or ethnicity, including
African-Americans, Hispanic-Americans, Native Americans, Asian-Americans, and Pacific Islanders,
6) previously identified impaired fasting glucose or impaired glucose tolerance, 7) history of
gestational diabetes or delivering a baby weighing over 9 pounds, 8) sustained hypertension (135/80
mmHg or above), 9) HDL cholesterol level less than or at 35 mg/dL or a triglyceride level of 250
mg/dL or above, 10) history of polycystic ovary syndrome, and 11) history of vascular disease.
A number of the above risk factors, while independent risk factors for type 2 diabetes, have been
clustered together as “metabolic syndrome” (patient having at least 3 or more of the following
criteria: 1) abdominal obesity (i.e. waist circumference >102 cm in men and >88cm in women, 2)
triglyceride level >150 mg/dL, 3) HDL level <40 mg/dL in men and <50 mg/dL in women, 4) BP
>130/85 mm Hg., 5) fasting glucose level >110 mg/dL). Researchers have found that among
people (over the age of 50) with diabetes, the prevalence of metabolic syndrome was very high, and
those with diabetes and metabolic syndrome had the highest prevalence of coronary heart disease
(CHD).4
In a study published in Lancet in 2010, authors found that in the US population, screening for type 2
diabetes is cost effective when started between the ages of 30 years and 45 years, with screening
repeated every 3–5 years.5 They found compared with no screening, all screening strategies reduced
the incidence of myocardial infarction (3–9 events prevented per 1000 people screened) and
diabetes-related microvascular complications (3–9 events prevented per 1000 people). Most
strategies prevented a significant number of deaths (2–5 events per 1000 people). There was little or
no effect of screening on incidence of stroke (0–1 event prevented per 1000 people).5
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Revised January 2014
Other Organizations’ Recommendations:
In 2008, the U.S. Preventive Services Task Force found sufficient evidence to recommend routine
screening for diabetes mellitus in adults with sustained blood pressure (either treated or untreated)
greater than 135/80 mmHg (a “B” recommendation).6 They concluded there was insufficient
evidence to screen asymptomatic adults with blood pressure of 135/80 mmHg or lower. They
concluded that there was sufficient evidence to prove that tight glycemic control could significantly
reduce the macrovascular complications, such as myocardial infarction or stroke. Furthermore,
although the benefit of early detection has not yet been established for this asymptomatic group,
clinicians may decide to screen selected high-risk persons on other grounds, including the increased
predictive value of a positive test in individuals with risk factors and the potential (although
unproven) benefits of reducing asymptomatic hyperglycemia through diet and exercise.
The American Academy of Family Physicians has adopted the U.S. Preventive Services Task Force
recommendations concluding there is insufficient evidence to recommend for or against screening
asymptomatic adults with a blood pressure of 135/80 mm Hg or lower.7 The Expert Committee on
the Diagnosis and Classification of Diabetes Mellitus suggests that early detection, and consequently
early treatment, might well reduce the burden of type 2 diabetes and its complications.1 The Expert
Committee recommended screening should be focused on higher risk individuals to be most cost
effective. The Canadian Task Force on the Periodic Health Examination began work on revising
their guidelines for screening for diabetes in 2010. Earlier guidelines concluded there is fair evidence
to screen adults with hypertension and hyperlipidemia for type 2 diabetes to prevent cardiovascular
events and death.8 They also conclude there is good evidence to recommend lifestyle interventions
for overweight individuals with impaired glucose tolerance to reduce the incidence of progression to
diabetes.
According to the American Diabetes Association's (ADA) position statement of 2011, screening for
diabetes as part of routine medical care should be considered at 3 year intervals for all adults with a
BMI > 25 kg/m2 and one or more risk factors for diabetes.1 Screening of those without any
additional risk factors should begin every three years at age 45 years. The ADA concludes that while
both A1C and oral glucose tolerance tests are suitable screening tests for diabetes, the fasting blood
sugar is strongly preferred because it is easier and faster to perform, more convenient and acceptable
to patients, and less expensive. Due to the high prevalence of many of the above risk factors in the
Gundersen service area, routine screening of adults with BMI > 25 kg/m2 every 3 years is
recommended.
References cited:
1. American Diabetes Association. Standards of Medical Care in Diabetes - 2011. Diabetes Care
January 2011 34:S11-S61; doi:l0.2337/dcll-S011/
2. Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2011. Atlanta, GA:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
Available at:
http://www.cdc.gov/diabetes/pubs/factsheet11.htm Accessed 3/2/2011.
3. Harris MI. Undiagnosed NIDDM: clinical and public health issues. Diabetes Care. 1993;16:64252.
4. Alexander CM, Landsman PB, Teutsch SM, Haffner SM. NCEP-defined metabolic syndrome,
diabetes, and prevalence of coronary heart disease among NHANES III participants age 50 years
and older. Diabetes. 2003;52:1210-14.
13
Revised January 2014
5. Kahn R, Alperin P, Eddy D, et al., Age at initiation and frequency of screening to detect type 2
diabetes: a cost-effectiveness analysis. Lancet 2010; 375: 1365–74.
6. US Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville, MD.
Screening for Type 2 Diabetes mellitus in Adults, Topic Page. June 2008.
http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm Accessed 3/2/2011.
7. American Academy of Family Physicians. Recommendations for clinical preventive services.
http://www.aafp.org/online/en/home/clinical/exam/diabetes.html Accessed 3/2/2011.
8. Feig DS, Palda VA, Lipscombe L with the Canadian Task Force on Preventive Health Care.
Screening for type 2 diabetes mellitus to prevent vascular complications: updated recommendations
from the Canadian Task Force on Preventive Health Care. CMAJ 2005;172:177-179.
Approved May 22, 2013.
Screening for Breast Cancer
Recommendation:
Women should begin screening mammograms yearly beginning at age 40.
Clinicians should consider the health and life expectancy of their patient when deciding if they
should continue to encourage a woman over the age of 74 to have screening mammography.
There is insufficient evidence to recommend for or against teaching or performing breast selfexamination (BSE). Clinical breast exams should be a part of a periodic health exam beginning at age
20, although no clinical trial demonstrates a reduction in mortality based on annual clinical breast
examination.
Disease and basis for recommendation:
Breast cancer is the most common non-skin malignancy among women in the United States. There
was an estimated 230,480 women diagnosed with invasive breast cancer in 2011, and 39,520 deaths.1
If detected early, the five-year survival rate for localized breast cancer is 98.6%.1 Numerous
randomized trials, as well as population-based screening evaluations, have clearly shown that
mammography reduces the risk of dying from breast cancer. Early detection of breast cancer by
mammography also leads to a greater range of treatment options, including less-aggressive surgery
(e.g., lumpectomy vs. mastectomy) and less-aggressive adjuvant therapy1 The combined randomized
clinical trials for screening mammography have demonstrated an 18% reduction in breast case
mortality for women age 40-49 and a 22% reduction for women age 40-64. The major difference in
mortality in the various randomized trials is noted primarily in the tumor size and stage of breast
cancer detected at screening. Trials where breast cancer was detected at small size and early stage
resulted in greater reduction in breast cancer mortality, while trials that detected large tumors and
advanced stage demonstrated little or no reduction in mortality.
Mammography is the best available method to detect breast cancer in its earliest, most treatable
stage – an average of 1 to 3 years before a woman can feel a lump. Women that are at increased risk
of breast cancer include those with a family history of breast cancer in a mother or sister, early age at
menarche (<12 years), late age at first birth (>30 years) or never having children, a previous breast
biopsy revealing atypical hyperplasia, postmenopausal hormone therapy, obesity (especially excess
14
Revised January 2014
weight gain after menopause), use of alcohol (one or more drinks daily), and previous chest radiation
to treat a different cancer.1
Although the U.S. Preventive Services Task Force in 2009 changed their recommendations and are
against screening women between the ages of 40-49,2 Gundersen has chosen to follow the
recommendations of the American Cancer Society,3 the American College of Obstetricians and
Gynecologists,4 and the American College of Radiology.5 The American Cancer Society
recommendations in 2010, and updated in 2013, indicate women at average risk for breast cancer
should begin annual mammography at age 40 and continue for as long as a woman is in good
health.3 The most compelling reasons to conduct annual screening for women age 40-49 comes
from studies examining tumor sojourn times (the duration of the detectable pre-clinical phase).6-7
The tumor sojourn times are shorter for younger ages and lengthen with increasing age. In addition,
shorter screening intervals result in detection of less aggressive tumors and at smaller sizes.
Other Organizations’ Recommendations:
The U.S. Preventive Services Task Force released its recommendations regarding breast cancer
screening, changing its position on initiating screening at age 40. The recommendations encourage
mammography every 2 years for all women beginning from ages 50.2 The Task Force found that
screening women younger than 50 was not supported by the existing evidence. Further, they found
insufficient research data to evaluate the effects of screening for breast cancer over age 74. Because
the risk for breast cancer is high after age 70, the Task Force indicated the benefits of
mammography might outweigh the risks and urged clinicians to consider co-morbid conditions of
the patient, and life expectancy when making recommendations to the patient.
In addition to the ACS,3 the American College of Obstetricians and Gynecologists (ACOG),4 and
the Society of Breast Imaging and the Breast Imaging Commission of the American College of
Radiology (ACR),5 all recommend screening with mammography and CBE beginning at age 40. The
Institute for Clinical Systems Improvement (ICSI) recommends screening mammography every one
to two years for women between the ages of 50 and 75 years, but left mammography for women 4049 years of age and over age of 75 years at the discretion of the clinician and patient.8 The Canadian
Task Force on Preventive Health Care updated their guidelines for breast cancer screening in 2011.9
The recommended against screening women age 40-49 years of age. They recommend screening
every two to three years for women aged 50-74 years, and made no recommendations for women
age 75 years and older.
References cited:
1. American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Atlanta: American Cancer
Society, Inc. Accessed at
http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/ac
spc-030975.pdf on 2/27/2013.
2. U.S. Preventive Services Task Force. Screening for Breast cancer: U.S. Preventive Services Task
Force Recommendation Statement. Ann Intern Med 2009;151:716-726.
3. American Cancer Society. Detailed Guide: Breast Cancer 2012. Accessed at:
http://www.cancer.org/acs/groups/cid/documents/webcontent/003090-pdf.pdf on 2/27/2013.
4. American College of Obstetricians and Gynecologists. Breast cancer screening. Washington DC:
American College of Obstetricians and Gynecologists ACOG; 2011 Aug 11 p. (ACOG practice
bulletin; no 122).
15
Revised January 2014
5. Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations
from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast
ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll
Radiol 2010;7:18-27.
6. Tabar L, Duffy SW, Vitak B, et al. The natural history of breast carcinoma: what have we learned
from screening? Cancer 1999;86:449-462.
7. Tabar L, Faberberg G, Day NE, et al. What is the optimum interval between mammographic
screening examinations? An analysis based on the latest results of the Swedish two-county breast
cancer screening trial. Br J Cancer 1987;55:547-551.
8. Institute for Clinical Systems Improvement. Health Care Guideline: Preventive Services for
Adults, 2012. Accessed at: http://www.icsi.org on 2/27/13.
9. Canadian Task Force on Preventive Health Care. Recommendations on screening for breast
cancer in average-risk women aged 40-74 years. CMAJ 2011;183:1991-2001.
Approved on 3/14/13
Screening for Cervical Cancer
Recommendation:
Cervical cancer screening should begin at age 21 years. Women younger than age 21 years should
not be screened regardless of the age of sexual initiation or the presence of other behavior-related
risk factors, including pregnancy. Both liquid-based and conventional methods of cervical cytology
collection are acceptable for screening.
Women aged 21–29 years should be tested with cervical cytology alone, and screening should be
performed every 3 years.
For women aged 30–65 years, co-testing with cytology and HPV testing every 5 years is preferred.
Screening with cytology alone every 3 years is acceptable. Annual screening should not be
performed.
Screening by any modality should be discontinued after age 65 years in women with evidence of
adequate negative prior screening results and no history of CIN 2 or higher. Adequate negative prior
screening results are defined as three consecutive negative cytology results or two consecutive
negative co-test results within the previous 10 years, with the most recent test performed within the
past 5 years.
In women who have had a hysterectomy with removal of the cervix (total hysterectomy) and have
never had CIN 2 or higher, routine cytology screening and HPV testing should be discontinued and
not restarted for any reason.
Women who have a history of the following should not follow routine screening guidelines:
•
•
•
•
Cervical cancer: Per established protocols
HIV infection: Cervical cytology twice in the first year following diagnosis, then yearly thereafter
Immunocompromised: Consensus recommendation is yearly cervical cytology
Exposure to diethylstilbestrol in utero Consensus recommendation is yearly cervical cytology
16
Revised January 2014
Disease and basis for recommendation:
Approximately 12,340 new cases of cervical cancer were predicted in 2013 in the United States;
4,030 women were expected to die from cervical cancer.1 The incidence of cervical cancer in the
United States has decreased more than 50% in the past 30 years because of widespread screening
with cervical cytology.2 In 1975, the rate was 14.8 per 100,000 women. By 2008, it had been reduced
to 6.6 per 100,000 women. Mortality from the disease has undergone a similar decrease from 5.55
per 100,000 women in 1975 to 2.38 per 100,000 women in 2008.
Although human papilloma virus (HPV) is the cause of nearly all cervical dysplasia and cervical
cancer, most HPV-related types of cervical neoplasia are very slow to progress. On average, severe
dysplasia may take 3–7 years to progress to invasive cervical cancer. Therefore, this rather indolent
disease course is well suited to less frequent testing and as Schiffman and Solomon stated, “It is a
challenging time to be a clinician or health planner dedicated to cervical cancer prevention.3 Even in
the most wealthy regions, using vaccination, cytology and HPV testing without careful planning
would invite waste and, more importantly, overtreatment.”
Data from studies screening women post hysterectomy found little-to-no increased risk of cervical
cancer, and no documented improvement in clinical outcomes.
Certain risk factors can increase the risk of developing cervical cancer. These include: early onset of
sexual intercourse, a greater number of lifetime sexual partners, and cigarette smoking. Infection
with high-risk strains of HPV, acquired through sexual activity, is the most important risk factor for
cervical cancer. Cervical cancer does not appear to have a genetic inheritance pattern, thus family
history of cervical cancer should not influence screening decisions.
Detection of cervical cancer in its earliest stages is lifesaving. The five-year survival rate for women
with localized cervical cancer is 92%, whereas it is only 13% for distant, metastatic disease.4 Thus,
early detection is extremely important.
Other Organizations’ Recommendations:
The American College of Obstetricians and Gynecologists,5 the U.S. Preventive Services Task
Force,6 and the American Cancer Society,7 recommendations were modified in 2012 or 2013. All are
in alignment with the recommendations to begin cervical cancer screening at age 21. Women aged
21 to 29 should have a Pap test every 3 years and no HPV testing should be done with this age
group. From age 30 to 65, the preferred method of screening would with a Pap test combined with
HPV test every 5 years. Another option would be a Pap test every 3 years. Women at higher risk (as
specified above) should be screened more often.
References cited:
1. American Cancer Society. What are the key statistics about cervical cancer? Atlanta: American
Cancer Society, 2013. Available at:
http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-key-statistics accessed
on 5/8/13.
2. National Institutes of Health, National Cancer Institute. Health, 2007. Table 54.
3. Schiffman M, Solomon D. Editorial. JAMA 2009; 302:1809-10
4. Ries LA, Kosary CL, Hankey BF, et al., eds.: SEER Cancer Statistics Review 1973-1995. Bethesda,
MD: National Cancer Institute, 1998.
17
Revised January 2014
5. The American College of Obstetricians and Gynecologists (ACOG) [Web site]. ACOG Practice
Bulletin. Number 109, December 2012. Cervical Cytology Screening
6. Moyer VA on behalf of the U.S. Preventive Services Task Force. Screening for Cervical Cancer:
U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2012;156:880891.
7. American Cancer Society. Cervical Cancer: Prevention and Early Detection. Available at:
http://www.cancer.org/cancer/cervicalcancer/moreinformation/cervicalcancerpreventionandearlyd
etection/cervical-cancer-prevention-and-early-detection-toc accessed on 5/8/13.
Approved on 2/18/2013
Screening for Chlamydia
Recommendation:
All sexually active females aged 16-25 should be screened annually for chlamydial infection. Risk
factors for chlamydia include having new or multiple sexual partners, a prior history of sexually
transmitted disease (STD), and using barrier contraceptives inconsistently.
Disease and Basis for Recommendation:
Chlamydia, caused by the bacterium, Chlamydia trachomatis, is the most common infectious disease
reported to the Centers for Disease Control. In 2011, 1,412,791 chlamydial infections were reported
to CDC from 50 states and the District of Columbia.1 Under-reporting is substantial because most
people are not aware that they may be infected. Approximately 2.8-9.4% of females ages 16-25 have
been infected with chlamydia. Of all cases, 80% are in females between the ages of 16 and 25.
Because the cervix of teenage girls and young women is not fully matured, they are at a high risk for
infection if sexually active. Often the symptoms of chlamydia are mild or absent and the condition
goes unrecognized. If untreated however, chlamydial infections can progress to serious reproductive
and other health problems with short and long-term consequences. Pelvic inflammatory disease
develops in 20-40% of women with chlamydia infection. The estimated direct/indirect cost of PID
alone in the Unites States for 2000 was $9 billion.2-3 Because of the high prevalence of chlamydia in
young women, and because 60-70% of women with chlamydia are without symptoms, annual
screening is recommended.
Other Organizations’ Recommendations:
The US Preventive Services Task Force found good evidence for screening all sexually active
women aged 25 and younger for chlamydial infection.4 Women and adolescents through age 25 are
at the highest risk for chlamydial infection. The US Preventive Services Task Force did not
recommend a frequency for screening, however, since pap smear testing among sexually active
women with multiple partners is recommended yearly.
The Centers for Disease Control and Prevention recommends annual screening of all sexually active
women aged < 25 years, as is screening of older women with risk factors (e.g., multiple or new sex
partners.)5
The Canadian Task Force on Preventive Health Care recommends that all members of high-risk
groups be screened for chlamydial infection.6 The American College of Obstetricians and
Gynecologists recommends routine screening for chlamydial infection for all sexually active
18
Revised January 2014
adolescents and other asymptomatic women at high risk for infection.7 In 2000, annual chlamydia
screening of sexually active women between the ages of 15 and 25 years was added to the National
Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS) quality
measures.8
References cited:
1. Centers for Disease Control. Surveillance 2006. Chlamydia. Accessed at
http://www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm. Accessed on 5/16/13.
2. Washington AE, Katz P. Cost of and Payment source for Pelvic Inflammatory Disease; Trends
and Projections, 1983-2000. JAMA 1991; 266: 2565-69.
3. Mangione-Smith R, O’Leary J, McGlynn EA. Health and cost-benefits of chlamydia screening in
young women. Sex Trans Dis 1999; 26:309-316.
4. U.S. Preventive Services Task Force. Screening for Chlamydial Infection: U.S. Preventive Services
Task Force Recommendation Statement. Ann Intern Med 2007;147:128-134.
5. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines.
2006. MMWR Recomm Rep. 2006;55:1-94)
6. Davies HD, Wang EEL. Periodic health examination, 1996 update: 2. Screening for chlamydial
infections. CMAJ 1996, 154:1631-1644.
7. American College of Obstetricians and Gynecologists, ACOG Committee on Primary Care.
Committee Opinion No. 229. Washington DC: American College of Obstetricians and
Gynecologists, 1999.
8. National Committee for Quality Assurance. HEDIS 2000: The health plan employer data and
information set. Volume 1: Narrative—What's in it and why it matters. Washington, DC: National
Committee for Quality Assurance, 2000.
Approval pending, May, 2013
Screening for Colorectal Cancer
Recommendation:
Asymptomatic, average risk adults, age 50 to 75 years should be screened for colorectal cancer with a
colonoscopy every ten years. Screening in patients over age 75 should be individualized based on the
patient’s health. Screening should never be done in patients whose life expectancy is less than 5
years. When colonoscopy is not available or preferred, a single fecal immunochemical test (FIT)
completed yearly either in the patient’s home or in the office setting is an acceptable alternative. If
the FIT test is not available, annual FOBT testing (three samples) continues to be an option.
Flexible sigmoidoscopy or CT colonography (virtual colonoscopy) every 5 years are also options.
The clinician should provide information to the patient about the benefits and limitations of the
various screening tests available so that they may make an informed decision. Screening
recommendations change if an adenoma or cancer is found.
Patients with a personal or family history of colon cancer or colon adenomas (in a first degree
relative) should undergo a colonoscopy, beginning at age 40 (or 10 years before the age of cancer in
the first degree relative.) If the patient has no adenomas at age 40, they should return every 5 years if
the relative was younger than age 60, or every 10 years if the relative was over 60. Patients with a
19
Revised January 2014
hereditary colorectal cancer syndrome should undergo yearly colonoscopy. Patients with ulcerative
colitis or Crohn’s Colitis of 7 to 10 years duration should begin colonoscopic surveillance every 1-3
years.
Disease and basis for recommendation:
Colorectal cancer can originate anywhere within the large intestines. The majority of colorectal
cancers develop from precancerous changes or growths (polyps) inside the lining of the rectum or
colon. Colorectal cancer is the second leading cause of cancer death in the U.S. In women, it ranks
third after lung and breast cancer, and in men, it ranks third after lung and prostate cancer.1
Incidence and mortality from colorectal cancer are similar in both men and women and have
declined significantly over the past 10 years.1 While the five year survival rate has increased from
51% in 1975 to 67% for cases diagnosed in 1999-2006,1 142,820 new cases, and 50,830 people are
expected to die from colorectal cancer in 2013.2-3
The risk of colorectal cancer increases with age. Nearly 80% of all colorectal cancer patients are over
the age of 55.3 Additional risk factors include: ethnicity (African American men and women are at
greater risk of developing and dying from colorectal cancer than any other racial group), a personal
or family history of colorectal cancer or adenomatous polyp, familial syndromes like FAP or
HNPCC, or a history of inflammatory bowel disease or Crohn’s disease. Behavioral risk factors
include a diet high in animal fats, tobacco use, and physical inactivity. Persons considered high risk
should undergo colon cancer screening beginning at age 40 or earlier, as necessary.
Early colon cancer usually has no symptoms. Clinicians seeing patients who present with a change in
their bowel habits, bleeding from the rectum or blood in their stool, cramping or gnawing stomach
pain, decreased appetite, weakness and fatigue should be evaluated for colorectal cancer.
Unfortunately, the signs and symptoms of colorectal cancer typically occur in the advanced stages of
the disease.
Other Organizations’ Recommendations:
The US Preventive Services Task Force recommends screening for colorectal cancer for all adults,
ages 50 to 75 years. They found good evidence that a screening colonoscopy every 10 years, annual
screening with high-sensitivity FOBT, or sigmoidoscopy with FOBT every 3 years reduces
colorectal cancer mortality.4 They recommend against screening adults over age 75, indicating that
the likelihood of detection and early intervention declines after age 75 because of the long average
time between adenoma development and cancer diagnosis. They also found insufficient evidence to
assess the benefits and harms of CT colonography and fecal DNA testing as screening modalities
for colorectal cancer.
The American Cancer Society Colorectal Cancer Advisory Group, the US Multi-Society Task Force
and the American College of Radiology Colon Cancer Committee developed a consensus guideline
in 2006-07, with an update in 2008.5 In this consensus guideline, they recommend sigmoidoscopy
every five years beginning at age 50 or a colonoscopy every 10 years. They also indicate that a
double-contrast barium enema every 5 years or CT colonography (virtual colonoscopy) every 5 years
is acceptable.5 The Institute for Clinical Systems Improvement (ICSI) recommends screening for all
adults ages 50 and over with any of the following methods: CT colonography every five years, a
sigmoidoscopy every 5 years with or without stool test for occult blood annually, a colonoscopy
every 10 years, or stool testing- guaiac-based fecal occult blood testing annually or fecal
immunochemical testing (FIT) annually.6 The American Academy of Family Physicians (AAFP)
20
Revised January 2014
recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or
colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years.7
References cited:
1. Altekruse S, Kosary C, Krapcho M, et al., eds. SEER Cancer Statistics Review 1975-2007,
http://seer.cancer.gov/csr/1975-2007/, based on November 2009 SEER data submission, posted to the
SEER web site, April 2010. Bethesda, MD: National Cancer Institute; 2010.
2. American Cancer Society. Key statistics about colorectal cancer. Accessed at:
http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-keystatistics on 3/14/13
3. American Cancer Society. Colorectal Cancer Facts & Figures 2011-2013. Atlanta: American Cancer
Society, 2011.
4. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force
recommendation statement. Ann Intern Med. 2008; 149:627-637.
5. American Cancer Society Colorectal Cancer Advisory Group, US Multi-Society Task Force and the
American College of Radiology Colon Cancer Committee. Screening and surveillance for the early
detection of colorectal cancer and adenomatous polyps, 2009. CA Cancer J Clin 2008;58:130-160.
6. Institute for Clinical Systems Improvement. Health Care Guideline: Colorectal Cancer Screening, 2012.
Accessed at: http://www.icsi.org on 4/18/13.
7. American Academy of Family Physicians. Colorectal Cancer, 2008. Accessed at:
http://www.aafp.org/online/en/home/clinical/exam/colorectalcancer.html on 4/18/13.
Approved January 13, 2014
Screening for Impaired Vision
Recommendation:
A comprehensive eye examination for the low risk adult should be conducted at least once every 2
to 4 years for adults 18-64 years of age, and every 1 to 2 years for those adults ages 65 years and
older. Patients found to have risk factors for eye disease may require more frequent evaluations.
Disease and basis for recommendation:
Eye and vision disorders have broad implications in health care and quality of life. Data from the
National Health and Nutrition Examination Survey (NHANES) estimates approximately 14 million
individuals ages 12 years or older have visual impairment, and of these, more than 11 million could
have improvement with refractive correction.1 Over 55% of the US population wears corrective
lenses. About 25% of adults have myopia; presbyopia, the natural age-related loss of eye focusing
ability, usually begins between ages 38 and 45 and the prevalence is virtually 100% by age 50.2 The
Centers for Disease Control and Prevention indicates that the economic impact of vision loss has
approached $51 billion in the United States.3 About 1% of people over 40 years have bilateral
blindness. The leading causes of visual impairment in elderly people are presbyopia, cataracts, agerelated macular degeneration (ARMD), glaucoma and diabetic retinopathy. Additionally, adults at
risk include those with diabetes, hypertension, or a family history of ocular disease, those working in
occupations that are highly demanding visually or eye hazardous, those taking prescription or
nonprescription drugs with ocular side effects, those wearing contact lenses, and those with other
health concerns or conditions.
21
Revised January 2014
The American Optometric Association recommends routine eye exams for the asymptomatic adult
every two to three years for adults 18-40 years of age, every 2 years for ages 41-60, and annually for
adults 61 years and older.4 For the at-risk adult, eye exams should occur every one to two years from
18 to age 60, and annually thereafter. Their guidelines are because many eye and vision disorders
create no obvious symptoms; therefore, individuals are often unaware that problems exist. They
state that early detection, diagnosis, and treatment are important for maintaining clear, comfortable
vision and good ocular health and, when possible, preventing permanent vision loss. They reference
a study that estimates approximately 92,700 new cases of blindness each year would have been
curable or preventable through timely detection and treatment.5
Other Organizations’ Recommendations:
The US Preventive Services Task Force revised its vision screening recommendations in 2009 and
found insufficient evidence to recommend for or against vision screening for older adults and left it
at the discretion of the clinician.6 The Task Force found insufficient evidence to recommend routine
performance of tonometry by primary care physicians as an effective screening test for glaucoma or
intraocular hypertension.7
The American Academy of Ophthalmology (AAO) recommends periodic comprehensive eye
evaluations for adults.8 For the asymptomatic low risk adult under age 40, they recommend a
comprehensive exam every 5-10 years. For adults between 40 and 64 years of age, they recommend
a comprehensive exam should be done every two to four years, and every one to two years for adults
over age 65. The rationale for these exams is to detect ocular disease that is prevalent in the adult
population in order to provide early treatment and thereby preserve visual function. The most
prevalent eye conditions that may be asymptomatic are glaucoma, diabetic retinopathy and agerelated macular degeneration. Furthermore, they recommend the frequency of ocular examinations
should depend on the individual's age, race, past ocular history, medical history, family history of eye
disease, and the types of symptoms or ocular findings encountered. If significant ocular disease is
detected, the frequency of examination will depend on the severity of the condition, the response to
therapy (or surgery), and the potential for detecting progression of the abnormality.
The American Academy of Family Physicians concluded there was insufficient evidence to
recommend screening for visual difficulties in elderly adults.9 The Institute for Clinical Systems
Improvement (ICSI) in their Health Care Guideline: Preventive Services for Adults, released in
September of 2010, recommended that objective vision testing (using Snellen charts) for
asymptomatic patients is recommended every 2 to 10 years only for elderly adults over age 65.10
References cited:
1. Vitale S, Cotch MF, Sperduto RD. Prevalence of visual impairment in the United States. JAMA
2006; 295:2158-2163.
2. American Optometric Association. Optometric Clinical Practice Guideline. Comprehensive Adult
Eye and Vision Examination. St. Louis, MO: American Optometric Association, 1997.
3. Centers for Disease Control and Prevention. Available at:
http://www.preventblindness.org/research/Impact_of_Vision_Problems.pdf
(Accessed 10/1/2010)
4. American Optometric Association Optometric Clinical Practice Guideline Comprehensive Adult
Eye and Vision Examination. 1005. Available at: http://www.aoa.org/documents/CPG-1.pdf
(Accessed 10/1/10)
5. Chiang Y, Bassi LJ, Javitt JC. Federal budgetary costs of blindness. Millbank Q, 1992; 2:336-7.
22
Revised January 2014
6. US Preventive Services Task Force. Screening for impaired visual acuity in older adults: US
Preventive Services Task Force Recommendation Statement. Ann Intern Med 2009;151:37-43.
7. US Preventive Services Task Force. Screening for Glaucoma, Topic Page. March 2005. U.S.
Preventive Services Task Force. Available at:
http://www.uspreventiveservicestaskforce.org/uspstf/uspsglau.htm (Accessed 5/17/2013)
8. American Academy of Ophthalmology, Frequency of Occular Exams. San Francisco: American
Academy of Ophthalmology, 2009.
9. American Academy of Family Physicians. Recommendations for clinical preventive services.
Available at: http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/CPS/rcps082005.Par.0001.File.tmp/June2010.pdf (Accessed 10/1/2010).
10. Institute for Clinical Systems Improvement. Health Care Guideline: Preventive Services for
Adults, Sixteenth Edition/September 2010 Available at:
http://www.icsi.org/preventive_health_care/preventive_health_care__guidelines_for_.html
Approved May 29, 2013.
Screening for Osteoporosis
Recommendation:
It is recommended that women aged 65 or older be screened, at least once, for osteoporosis via
dual-energy x-ray absorptiometry of the hip and lumbar spine.
In addition, women younger than age 65 whose 10-year fracture risk is equal to or greater than that
of a 65 year old white women without additional risk factors should be screened at least once. This
can be easily determined by using the FRAX tool 1 which has been developed by the WHO. A score
of 9.3% is equivalent to a women aged 65 years. Additionally, women with a family history, chronic
steroid use, previous radiation therapy, or malnutrition (low body weight or BMI < 20 kg/m2), or a
fracture of any type over the age of 45 should have bone density testing.
Screening in males is left to the discretion of the clinician, however, those having a 9.3% risk of
fracture in the next ten years (as assessed by the FRAX) or with risk factors such as a fracture, family
history, chronic steroid use, hypogonadism, or hyperparathyroidism should be screened.
Disease and basis for recommendation:
Osteoporosis is the most common metabolic bone disease in humans. An estimated 9% of
American adults aged 50 years and over have either osteoporosis or low bone mass. The prevalence
of osteoporosis or low bone mass differed by age, sex, and race and ethnicity. Roughly one-half of
older adults in the population had low bone mass at either the femur neck or lumbar spine. Fortyeight percent of older adults in the United States had normal bone density at both the femur neck
and lumbar spine. The prevalence was higher in women and increased with age. According to data
from the National Health and Nutrition Examination Survey III for 2005-2008, 2% of men (0.8
million) and 10% (4.5 million) of women over the age of 50 in the United States have osteoporosis,
and an additional 52% women (21.8 million) have low bone density at the hip.1 One out of every
1
http://www.shef.ac.uk/FRAX/
23
Revised January 2014
two white women will experience an osteoporotic fracture at some point in her life, placing a huge
burden on the family, and health care system and significantly jeopardizing her own health.2
Osteoporosis is a “disease characterized by low bone mass and microarchitectural deterioration of
bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk."3
Classically, osteoporosis is differentiated from disorders, such as osteomalacia and osteogenesis
imperfecta, by the fact that there is no obvious defect in mineralization or the structure of collagen.
Post-menopausal osteoporosis is a silent disease until it is complicated by fragility fractures. Postmenopausal bone loss is most rapid during the first ten years after the onset of menopause. The risk
for fracture increases steadily as bone density declines, with no threshold. Bone loss due to estrogen
deficiency and advancing age affects the whole skeleton. Because the rate of remodeling is greater in
cancellous bone rather than cortical bone, bone loss manifests itself at predominantly cancellous
skeletal sites such as the lumbar spine.4 Compression fractures of the vertebrae can occur
spontaneously or with minimal trauma. Low body weight and weight loss are important risk factors
for osteoporotic fractures. Other osteoporotic fractures are commonly of the hip and wrist;
however, most fractures in older adults are partially related to low bone mass.
The incidence of hip and spine fractures in men increases with age and is about one third that in
women.5 Men often have vertebral deformities associated with trauma earlier in life. In men, an
exponential increase in hip fractures tends to occur after age 75 years of age, although the rate is still
less than in age-matched women.6 Primary osteoporosis in men is associated with low estrogen and
high sex hormone–binding globulin (SHBG) levels.7
Absolute fracture risk methodology provides a markedly improved method to assure that people
with the highest fracture risk get treated. Those at highest risk include postmenopausal women and
older men with a diagnosis of osteoporosis, based on a BMD test T-score of -2.5 or lower, or those
with a clinical diagnosis based on having sustained a hip or spine fracture. In addition, absolute
fracture risk calculations help to resolve many of the questions about management for people with
low bone mass, also called osteopenia. These are people with a T-score between -1.0 and -2.5 on
their bone mineral density (BMD) test.8
The WHO algorithm takes into account not only bone mineral density (BMD) at the hip but also
nine specific clinical risk factors for osteoporosis and related fractures. NOF has adapted this
algorithm for the U.S. and incorporates not only fracture outcome and mortality data from U.S.
women and men, but also cost effectiveness analysis to determine when it is cost effective to treat a
person with an osteoporosis medication to prevent a fracture.
24
Revised January 2014
Diagnostic Categories for Osteoporosis Based on Measurements of Bone Mineral Density8
Category
Definition
Normal
A value for BMD ± 1 SD of the young adult reference
mean
Low bone mass (osteopenia)
A value for BMD > 1 SD and < 2.5 SD lower than the
young adult mean
Osteoporosis
A value for BMD > 2.5 SD lower than the young adult
mean
BMD, bone mineral density; SD, standard deviation.
All women under age 65 who have one or more additional risk factors for osteoporosis should be
screened at the time of menopause. Risk factors include those with a family history of premature
osteoporosis, long term inadequate calcium intake, incidental plane films suggestive of suboptimal
bone density, chronic steroid use (defined as >5mg of prednisone or its equivalent per day for more
than 90 days),9 suspicious low stress fractures, cigarette smoking, and low body weight. Screening is
not advised for any patient, regardless of risk factors if it is clear that the results of screening will not
influence treatment.
The U.S. Preventive Services Task Force (USPSTF) updated its guidelines on screening for
osteoporosis in 2011.10-11 They concluded that a Bone Mineral Density (BMD) measurement be done
for all women aged 65 and older regardless of risk factors. They conclude that although methods to
identify risk for osteoporotic fractures are available and medications to reduce fractures are effective,
no trials directly evaluate screening effectiveness, harms, and intervals.10 The USPSTF further
recommends that for women who are younger than 65 whose 10-year fracture risk is equal to or
greater than that of a 65 year old white women without additional risk factors should be screened.
The new Clinician’s Guide by the National Osteoporosis Foundation applies the recently released
algorithm on absolute fracture risk called FRAX® by the World Health Organization (WHO).
FRAX® is also referred to as a 10-year fracture risk model and 10-year fracture probability. This
algorithm estimates the likelihood of a person to break a bone due to low bone mass or osteoporosis
over a period of 10 years.12 A FRAX score of 9.3% at any age, would be equivalent to a healthy 65
year-old women and would suggest screening.
No studies have determined the optimal intervals for repeated screening. The USPSTF suggests a
minimum of 2 years is needed between tests due to the limitations in the precision of testing. There
are no data to determine the precise age to stop screening. The USPSTF found insufficient evidence
of the benefits to screening in males at any age, though made a similar recommendation as younger
women, i.e. those with a 10-year fracture risk equal to or greater than that of a 65 year old white
woman without additional risk factors (FRAX score of 9.3% or higher) should be screened.
Other Organizations Recommendations:
The National Osteoporosis Foundation (NOF) recommends that a Bone Mineral Density (BMD)
measurement be done for all women aged 65 and older and all men age 70 and older, regardless of
risk factors.12 Additionally they recommend all postmenopausal women and men age 50 and older
25
Revised January 2014
are assessed of their risk using the FRAX, counseled on the risk of osteoporosis, advised on
adequate calcium and vitamin D consumption, recommended to participate in weight-bearing and
muscle strengthening exercise, and to avoid alcohol and excess alcohol intake.
The American Association of Clinical Endocrinologists’ guidelines made similar recommendations
to the NOF.4 They recommend screening women over the age of 65 regardless of risk factors and in
women 60 years or older who have sustained a fracture. They also recommend promotion of a diet
with adequate calcium consumption and overall good general nutrition, and adequate vitamin D
intake. They advocate regular, weight-bearing activity and strongly discourage the use of tobacco and
excess alcohol use.
The Canadian Task Force on Preventive Health Care recommended in 2004 screening for
osteoporosis in postmenopausal women to prevent fragility fractures (no or low trauma fractures).
Furthermore, although there was no direct evidence that screening reduced fractures, there was
good evidence that screening is effective in identifying postmenopausal women with low bone
mineral density and that treating osteoporosis can reduce the risk of fractures in this population.13
No updates have been made to their guideline since 2004.
In a position statement by the International Society for Clinical Densitometry, in addition to
recommending BMI for women age 65 and older, and women under age 65 with risk factors for
fracture, it was recommended that all men over the age of 70 be screened with BMD. Additionally
men with prior fragility fractures or other conditions widely recognized to increase the risk for bone
loss and fracture were recommended to receive BMD (e.g., hypogonadism, corticosteroid treatment,
hyperparathyroidism, alcohol abuse, anticonvulsant use, prior gastrectomy, etc.).14
References cited:
1. Centers for Disease Control and Prevention, National Center for Health Statistics. Osteoporosis
or low bone mass at the femur neck or lumbar spine in older adults: United States, 2005-2008.
NCHS Data Brief. 93: April 2012.
2. U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the
Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the
Surgeon General, 2004.
3. Consensus Development Conference. Diagnosis, prophylaxis and treatment of osteoporosis. Am
J Med 1993; 94:636–638.
4. American Association of Clinical Endocrinologists. Medical guidelines for clinical practice for the
diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract 2010;16(suppl 3).
5. Melton LJ III, Atkinson EJ, O'Connor MK, et al. Bone density and fracture risk in men. J Bone
Miner Res 1998; 13:1915–1923.
6. Drake MT, Khosla S. Male Osteoporosis. Endocrinol Metab Clin N Am 2012; 41:629-641.
7. Center JR, Nguyen TV, Sambrook PN, et al. Hormonal and biochemical parameters in the
determination of osteoporosis in elderly men. J Clin Endocrinol Metab 1999; 84:3626–3635.
8. WHO Scientific Group On The Assessment Of Osteoporosis At Primary Health Care Level.
World Health Organization 2007. Available at: http://www.who.int/chp/topics/Osteoporosis.pdf
Accessed 2/20/2013.
9. Buckley L, Greenwald M, Hochberg M, Lane N, et al. American College of Rheumatology Ad
Hoc Committee on Glucocorticoid-Induced Osteoporosis. Recommendations for the prevention
and treatment of glucocorticoid-induced osteoporosis: 2001 update. Arthritis Rheum. 2001;44:14961503.
26
Revised January 2014
10. Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R. Screening for osteoporosis: an update
for the U.S. Preventive Services Task Force. Ann Intern Med 2010;153(2):1-14.
11. U.S. Preventive Services Task Force. Screening for Osteoporosis: Recommendation Statement.
AHRQ Publication No. 10-05145-EF-2, January 2011. Available at:
http://www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.htm Accessed on
2/19/2013.
12. National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of
osteoporosis. Washington, DC, 2010.
13. Angela M. Cheung, Denice S. Feig, Moira Kapral, Natalia Diaz-Granados, Sylvie Dodin, and the
Canadian Task Force on Preventive Health Care. Prevention of osteoporosis and osteoporotic
fractures in postmenopausal women: recommendation statement from the Canadian Task Force on
Preventive Health Care. CMAJ. 2004; 170 :1665-1667.
14. International Society for Clinical Densitometry (ISCD). 2007. Official positions of the ISCD.
Available at: http://www.iscd.org/official-positions/2007-iscd-official-positions-adult/ Accessed
2/19/2013.
Approved on 3/14/13
27
Revised January 2014
COUNSELING
Counseling for Prostate Cancer Screening
Recommendation:
Gundersen recommends against screening for prostate cancer of asymptomatic, average risk males who are
younger than 55 years of age or older than 69 years of age. Those asymptomatic men with a life expectancy
of less than 10 years should also not be screened.
Clinicians should inform men between the ages of 50 and 69 years about the potential benefits and harms of
screening for prostate cancer. The decision to screen or not to screen should be based on the risks for
prostate cancer, the patient’s general health and life expectancy, and patient preferences.
This guideline does not apply to men at high risk for prostate cancer, which includes:
• African Americans,
• those with a first degree relative with prostate cancer, and
• those with symptoms that could be related to locally advanced or metastatic prostate cancer.
Symptoms include
• frequent urination,
• nocturia (increased urination at night),
• difficulty starting and maintaining a steady stream of urine,
• hematuria (blood in the urine), and
• dysuria (painful urination).
Disease and basis for recommendation:
Prostate cancer is the most common non-cutaneous cancer and is the second leading cause of cancer death
among North American men. In the United States in 2009, 206,640 men were diagnosed with prostate
cancer, and 28,088 men died from it.1 The National Cancer Institute estimates that approximately 238,590
new cases and 29,720 prostate-related deaths will occur in the United States during 2013.2 Approximately
one in six men will develop prostate cancer in their lifetime, and one in 36 men will die of prostate cancer.
Prostate cancer accounts for 42% of all male cancers (28% of all new cases), and 11% of male cancer-related
deaths.3
Despite its prevalence, the natural history of the disease is remarkably heterogeneous and many men with
prostate cancer do not suffer from symptoms or die of the disease. Prostate specific antigen (PSA) has
revolutionized screening for prostate cancer. Since it was introduced as a tumor marker in the 1980s, there
has been a steady decline in prostate cancer mortality of approximately 30%.3 Screening with PSA has also
been responsible for a shift toward detection of prostate cancer at earlier stages.4 Despite these findings, the
use of PSA as a screening test remains controversial. The National Cancer Institute (NCI) has stated that
there is insufficient evidence to establish whether a decrease in mortality occurs with screening by DRE or
PSA. They assert that while some observational studies of cohorts of men who had prostate screening did
result in a decrease in the mortality rate, there have not been consistent observations in all populations or
within a given population.5
28
Revised January 2014
Other Organizations’ Recommendations:
United States Preventive Services Task Force: The US Preventive Services Task Force in 2012
recommended against prostate specific antigen based screening for prostate cancer. Their recommendation
applies to men of all ages in the general population and not for the use of the PSA test for surveillance after
diagnosis or treatment of prostate cancer.6 They conclude that there is convincing evidence that the PSA
test often produces false-positive results, that when acted on, result in additional and unnecessary biopsies,
which could lead to pain, fever, bleeding, infection, transient urinary difficulties, or other issues.
American College of Physicians: In April of 2013, the American College of Physicians released a
guidance statement regarding prostate cancer screening.7 They reviewed the U.S. Preventive Task Force,
American Cancer Society, American Urologic Association, and American College of Preventive Medicine
guidelines in the process of issuing two guidance statements. They recommend that clinicians inform men
between the ages of 50 and 69 about the limited benefits and substantial harms of screening, consider the
health and life expectancy, and only screen with a PSA in patients who express a clear preference for
screening. They further recommend that clinicians do not use the PSA in men under age 50 or over age 69,
or in men with a life expectancy of less than 10 to 15 years.
ACP Talking Points with Patients:7
1. Prostate cancer screening with the PSA test is controversial.
2. PSA screening can detect prostate cancer, but for most men, the chances of harm from
screening with the PSA test outweigh the chances of benefit.
3. A small number of prostate cancer cases are serious and can cause death; however, the vast
majority of prostate cancer is slow-growing and does not cause death.
4. Most men who choose not to do PSA testing will not be diagnosed with prostate cancer and
will die of something else.
5. Patients who choose PSA testing are much more likely than those who decline PSA testing
to be diagnosed with prostate cancer.
6. The PSA test often does not distinguish between cancer cases that are serious and those
cases that are not serious. However, men with markedly elevated PSA levels (>10 μg/L) may
have a reduced chance of dying from prostate cancer by having surgical treatment.
7. The small potential benefit of prostate cancer screening corresponds to preventing, at most,
1 death caused by prostate cancer per 1000 men screened after 11 y of follow-up.
8. The potential harms of screening include:
• Problems interpreting test results: The PSA test result may be high because of an
enlarged prostate, but not because of cancer, or it may be low even though cancer is
present.
• If a prostate biopsy is needed, it, too, is not free from risk—the biopsy involves multiple
needles being inserted into the prostate under local anesthesia, and there is a risk for
infection or significant bleeding as well as risk for hospitalization (1.4%).
• If cancer is diagnosed, it will often be treated with surgery or radiation, which is
associated with risks. There is a small risk for death with surgery, loss of sexual function
(approximately 37% higher risk), and loss of control of urination (approximately 11%
higher risk) compared with no surgery. These risks may vary depending on patient and
surgeon characteristics and treatment method.
9. The PSA test is not “just a blood test.” It is a test that can open the door to more testing and
treatment that a man may not actually want and that may actually harm him. A man's
29
Revised January 2014
chances of being harmed are much greater than his chances of benefiting from the PSA test.
Thus, each man should have the opportunity to decide for himself whether to have the PSA
screening test.
10. Studies are ongoing, so clinicians expect to learn more about the benefits and harms of
screening, and recommendations may change over time. Men are also welcome to change
their minds at any time by asking for screening that they have previously declined or
discontinue screening that they have previously requested.
American Urological Association: In May of 2013, the American Urological Association changed their
recommendations on screening for prostate cancer.8 They recommend against PSA screening in men under
age 40 years and in men between 40 and 54 years who are at average risk. For men younger than 55 years at
higher risk (positive family history or African American race) they state that decisions regarding prostate
cancer screening should be individualized. For men ages 55 to 69, they recommended discussing the
potential benefits and harms associated with screening and treatment. Then based on shared decisionmaking considering the patient’s values and preferences decide whether to proceed with screening for
prostate cancer. In this age group, if the decision has been to screen, they suggest that a routine screening
interval of two years or more is preferred over annual screening. Finally, the AUA panel did not recommend
routine PSA screening for men over age 70 years or in any man with less than a 10 to 15 year life
expectancy.
References cited:
1. Centers for Disease Control and Prevention, National Center for Health Statistics. Available at:
http://www.cdc.gov/cancer/prostate/index.htm accessed on 5/17/13.
2. National Cancer Institute. Prostate Cancer. Available at:
http://www.cancer.gov/cancertopics/types/prostate accessed on 5/17/13.
3. Ries L.A., Melbert, D., Krapcho, M., et al (eds). SEER Cancer Statistics Review, 1975-2005,
National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2005/, based on
November 2007 SEER data submission, posted to the SEER web site, 2008.
4. Etsioni, R., Tsodikov, A., Mariotto, A. et al: Quantifying the role of PSA screening in the US
prostate cancer mortality decline. Cancer Causes Control, 19: 175, 2008.
5. National Cancer Institute. Cancer.gov - Prostate Cancer (PDQ®): Screening. Available at:
http://cancer.gov/cancerinfo/pdq/screening/prostrate/healthprofessional. Accessed 2/25/11.
6. U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task
Force Recommendation Statement. Ann Intern Med 2012;157:120-134.
7. Qaseem A et al. Screening for prostate cancer: A guidance statement from the Clinical Guidelines
Committee of the American College of Physicians. Ann Intern Med 2013 Apr 9.
8. American Urological Association. Early detection of prostate cancer: AUA guideline. Available at:
http://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm accessed on 5/3/13.
Approval pending, May 2013.
30
Revised January 2014
Tobacco Use and Dependence – Identification, Assessment and Treatment
1. Every patient seen within the clinic or hospital will have an assessment for tobacco use at every
encounter.
2. Tobacco use status should be documented with the patient’s vital signs. If the patient is identified
as a tobacco user, type, quantity and duration of tobacco use should be determined and documented
as well. The patient should be assessed regarding willingness to quit.
3. For those willing to quit at the time of visit, counseling intervention should be implemented
utilizing the 5’A’s (Ask, Advise, Assess, Assist, and Arrange).1-3
Ask – “Do you use tobacco?” (all patients)
Advise to quit. “Quitting tobacco is the most important thing you can do to protect your
health.” (all present tobacco users)
Assess willingness to make a quit attempt. “Are you ready to quit at this time?” (all present
tobacco users)
Assist in quit plan. Prescribe medication as appropriate. (for those ready to quit)
Arrange for follow-up
a. Ready to quit - follow-up within 24-48 hours of quit date.
b. Not ready to quit - follow-up within 3-4 weeks of appointment.
A plan of action for cessation should be in place prior to the end of the visit. A copy of the
Gundersen Cessation Workbook should be given and reviewed with the patient. (Workbook
available in the stockroom - item #3444). Follow-up telephone assessment and counseling
within the first week of quitting is encouraged. Consider referring patients to a tobacco quit
line:
•
•
•
Wisconsin and Iowa Tobacco Quit Line: 1-800-QUIT-NOW (1-800-784-8669)
Minnesota Quit Line: 1-888-354-PLAN (1-888-354-7526)
You can complete a Fax-to-Quit form (based on state of residence) and your patient will be
contacted by the quit line at a time specified by the patient.
4. Persons who are not ready to quit should receive motivational counseling to move them along the
continuum of cessation utilizing the 5 R’s (Relevance, Risk, Rewards, Roadblocks, and Repetition).
Relevance - discuss personal relevance of the harmful effects of tobacco use (children at home,
effects on health, previous quit attempts).
Risks - discuss acute, long-term and environmental risks to their tobacco use.
Rewards - help patient identify potential benefits to stopping tobacco use.
Roadblocks - help patient identify barriers to quitting and note elements of treatment that
could address barriers (problem-solving, pharmacotherapy.)
Repetition - intervention should be repeated every time an unmotivated patient enters the clinic
or hospital setting.
For those not ready to quit, the “Benefits of Quitting” handout should be given and
reviewed with patient.
5. Consider using Motivational Interviewing strategies with patients to enhance cessation process:
31
Revised January 2014
Express empathy – open ended questions, reflective listening, normalize feelings, support
autonomy
Develop discrepancy – reinforce and support change talk, build and deepen commitment
Dissolving Dissonance/Roll with resistance – ask permission to provide information
Support self-efficacy – help patient identify and build on past successes, offer options –
Quit line, benefits to quitting.
Special considerations:
Persons who do not currently use tobacco but who are at increased risk of adopting such behavior
should be advised to resist pressure to begin smoking or using smokeless tobacco, reinforcement for
their decision to quit or abstain, congratulations on their success at quitting and encouragement to
remain abstinent.
Pregnant women and parents with young children should receive information on the potential
harmful effects of smoking on fetal and child health. Furthermore, because of the serious risks of
smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be
offered extended or augmented psychosocial interventions that exceed minimal advice to quit.
Clinicians should offer effective smoking cessation interventions to pregnant smokers at the first
prenatal visit as well as throughout the course of pregnancy. Pregnant women who smoke and are
residents of the state of Wisconsin, should be referred to someone trained in the First Breath
program. Staff trained in First Breath can determine the eligibility of the pregnant patient as well as
recommend other resources.
There is a strong dose-response relation between the session length of person–to-person contact
and successful treatment outcomes. Intensive interventions are more effective than less intensive
interventions and should be used whenever possible. Certain strategies can increase the effectiveness
of counseling regarding tobacco use: direct, face-to-face advice and suggestions, scheduled
reinforcement, self-help materials, referral to community programs, and drug therapy. Person-toperson treatment delivered for four or more sessions appears especially effective in increasing
abstinence rates.4-6 The U.S. Preventive Services Task Force recommends that all patients should be
asked about their smoking status and encouraged to quit on a regular basis.7
References Cited
1. U.S. Department of Health and Human Services, The Health Consequences of Smoking: A
Report of the Surgeon General, Center for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.
2. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public
Health Service. May 2008.
3. Burke, et al. Treatment of tobacco dependence . Mayo Clinic Proceedings. 2008; 83: 479-484.
4. Miller, WR, Rollnick, Stephen. Motivational Interviewing, Third Edition: Helping People Change.
Third Edition, Guilford Press, New York, New York, 2012.
5. Hurt, et al. Treating tobacco dependence in a medical setting. CA: A Cancer Journal for
Clinicians. 2009;59;314-326.
6. Alexander V. Prokhorov; Karen Suchanek Hudmon; Salma Marani; Lewis Foxhall; Kentya H.
Ford; Nancy Stancic Luca; David W. Wetter; Scott B. Cantor; Frank Vitale; Ellen R. Gritz. Arch
32
Revised January 2014
Intern Med. 2010; 170: 1640-1646. Engaging Physicians and Pharmacists in Providing Smoking
Cessation Counseling
7. U.S. Preventive Services Task Force. Counseling and Interventions to Prevent Tobacco Use and
Tobacco-Caused Disease in Adults and Pregnant Women: U.S. Preventive Services Task Force
Reaffirmation Recommendation Statement. Ann Intern Med 2009;150:551-55.
Approved May 30, 2013.
Obesity Assessment and Counseling
Clinicians are encouraged to do a brief assessment to determine a patient’s general risk for obesity,
nutrition status and physical activity level and provide medical nutrition therapy, nutrition
counseling, education, and treatment as appropriate. Any patient with a body mass index (BMI) of
greater than 25 may be at risk for developing health problems and should be recommended to a
registered dietitian. BMI can be determined with the following calculation: weight in kilograms,
divided by height-squared, where height is in meters. The U.S. Preventive Services Task Force found
good evidence that BMI is reliable and valid for identifying adults at increased risk for morbidity and
mortality due to overweight and obesity.1 They also found fair to good evidence that high-intensity
counseling together with behavioral interventions aimed at skill development, motivation and
support strategies produces modest, sustained weight loss in obese adults.1
Clinicians are encouraged to do a brief assessment to determine a patient’s general nutrition status
and refer patients at nutritional risk to a registered dietitian who is the qualified professional to
provide medical nutrition therapy, nutrition counseling, education and treatment. Those patients at
greatest need for nutrition services include those with conditions such as diabetes, high cholesterol,
heart disease, hypertension, renal disease, or obesity. Medical nutrition therapy and nutrition
counseling services have been proven effective in treating and preventing life-threatening diseases.
The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against
behavioral counseling in primary care settings to promote physical activity.2 The Task Force did not
review the evidence for the effectiveness of physical activity to reduce chronic disease morbidity or
mortality, since this evidence has been well documented. In July of 1996, the Surgeon General’s
report was released on physical activity and health.3 This report assesses the role of regular physical
activity in preventing disease. The report highlighted the health benefits of a moderate level of
activity every day. The report also concludes that although the level of activity does not need to be
vigorous to provide health benefit, the amount of health benefit is directly related to the amount of
regular physical activity. Short periods of exercise several times each day is an acceptable
recommendation to patients who are more likely to comply with this.
Clinicians should provide all patients with information on the role of physical activity in disease
prevention and assist in selecting an appropriate type of exercise. Factors that should be considered
in designing a program include medical limitations and activity characteristics that both improve
health (e.g., weight bearing, increased caloric expenditure, enhanced cardiovascular fitness, low
potential adverse effects) and enhance compliance (e.g., low perceived exertion, cost,
inconvenience.) The patient should also be given instructions on how to perform the exercise safely
to reduce the risk of injuries. Clinicians who are unable to design an effective exercise program may
33
Revised January 2014
wish to refer patients to an accredited exercise specialist. The Centers for Disease Control and
Prevention (CDC) provides the following guidelines for adults:4
If...
Then...
You do not currently engage in regular physical activity,
you should begin by incorporating a few minutes of
physical activity into each day, gradually building up to 30
minutes or more of moderate-intensity activities.
You are now active, but at less than the recommended
levels,
you should strive to adopt more consistent activity:


moderate-intensity physical activity for 30 minutes
or more on 5 or more days of the week, or
vigorous-intensity physical activity for 20 minutes
or more on 3 or more days of the week.
You currently engage in moderate-intensity activities for at you may achieve even greater health benefits by increasing
least 30 minutes on 5 or more days of the week,
the time spent or intensity of those activities.
You currently regularly engage in vigorous-intensity
activities 20 minutes or more on 3 or more days of the
week,
you should continue to do so.
The CDC defines moderate-intensity as an activity that burns 3.5 to 7 calories per minute, such as
brisk walking, mowing the lawn, dancing, bicycling or swimming for recreation. Vigorous-intensity
activity is defined as an activity that burns more than 7 calories per minute such as jogging, heavy
yard work, high impact aerobic dance, lap swimming or bicycling uphill.
References Cited:
1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 3rd edition: Periodic
Updates. Screening for obesity in adults. Baltimore, MD. 2003.
2. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 3rd edition: Periodic
Updates. Physical Activity Counseling. Baltimore, MD. 2002.
3. US Department of Health and Human Services. Physical activity and health: a report of the
Surgeon General. Atlanta, Georgia: US Department of Health and Human Services. Public Health
Service, CDC, National Center of Chronic Disease Prevention and Health Promotion, 1996.
4. Centers for Disease Control and Prevention. Physical activity for everyone: recommendations.
(2006) Available at: http://www.cdc.gov/nccdphp/dnpa/physical/recommendations/adults.htm
34
Revised January 2014
Alcohol and Other Substance Abuse Counseling
Clinicians should routinely ask all adults to describe their use of alcohol and other drugs. Gundersen
recommends the use of Alcohol Screening and Brief Intervention (ASBI) at annual appointments,
and in cases where the patient presents to the healthcare setting with an injury or trauma. 1
ASBI is a targeted prevention program incorporating alcohol screening, brief feedback, and
motivational interviewing to assist patients in connecting their drinking behavior with their current
injury or medical problem.1 Patients are then encouraged to take action to reduce their risks. ASBI
has been demonstrated to reduce alcohol consumption and related injuries in targeted patients. It
has been shown to reduce drinking and driving six months following intervention by 32%, a 47%
reduction in repeat injuries requiring an emergency department visit or hospital admission at one
year and significant, prolonged reductions in alcohol consumption.2
The National Institute of Alcohol Abuse and Alcoholism offers specific guidelines for men and
women regarding the maximal thresholds for low-risk drinking.3 Men should not drink more than
fourteen drinks in any week and not more than four drinks in any given day. Women should not
drink more than seven drinks in any week and not more than three drinks in any given day. People
who drink below these levels may still be at risk for alcohol-related injuries, medical and/or other
alcohol-related problems. However, drinking above these amounts is known to place individuals at
high risk.
Patients should be asked to describe the quantity, frequency, and other characteristics of their use of
wine, beer, liquor, and other drugs. Certain questionnaires may be helpful to clinicians in assessing
important alcohol use patterns. An affirmative answer to at least two of the four questions in the
CAGE 2 instrument,4 for example, may provide useful information on the likelihood of a previous or
current problem with alcohol abuse. Routine measurement of biochemical markers, such as serum
GGT, and drug testing of urine or other body fluids are not recommended as the primary method
of detecting alcohol or other drug abuse in asymptomatic persons.
ASBI has been endorsed both by the Society for Academic Emergency Medicine for use in the
Emergency Department5-6 as well as by the U. S. Preventive Services Task Force,7-8 who find good
evidence for use in primary care settings.
Persons in whom drug abuse or dependence is suspected should receive further evaluation to
confirm the diagnosis and accuracy of test results and to rule out false positive results. Once the
diagnosis is confirmed, the clinician should inform the patient of the effects of the drug and should
develop a treatment plan for the patient and family that is tailored to the drug of abuse and the
needs of the patient. Many patients may benefit from referrals to appropriate consultants and
community programs specializing in the treatment of alcohol and other drug dependencies.
2
C:
A:
G:
E:
“Have you ever felt you ought to Cut down on drinking?”
“Have people Annoyed you by criticizing your drinking?”
“Have you ever felt bad or Guilty about your drinking?”
“Have you ever had a drink first thing in the morning to steady your nerves or get rid of a
hangover? (Eye-opener)?”
35
Revised January 2014
The U.S. Preventive Services Task Force recommends screening and behavioral counseling
interventions to reduce alcohol misuse by adults, including pregnant women, in primary care
settings.1 Alcohol misuse is strongly associated with health problems, disability, death, accident,
injury, social disruption and violence. Alcohol misuse patterns include binge drinking (drinking 5 or
more alcoholic beverages in one sitting), drinking and driving, or drinking to intoxication.
References Cited:
1. Office of Clinical and Preventive Services Indian Health Service. Alcohol screening and brief
intervetion (ASBI) program implementation and operations manual. Available at:
http://www.ihs.gov/nonmedicalprograms/nc4/Documents/ASBI_Manual.pdf assessed on 4/1/11
2. Academic ED SBIRT Research Collaborative. “The Impact of Screening, Brief Intervention, and
Referral for Treatment on Emergency Department Patients’ Alcohol Use.” Annals of Emergency
Medicine. 2007; 50: 699-710.
3. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A
Clinician’s Guide. 2005 Edition. National Institutes of Health Publication No 07-3769. Rockville,
Maryland.
4. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984; 252:1905-1907
5. D’Onofrio G, Degutis LC. “Preventive Care in the Emergency Department: Screening and Brief
Intervention for Alcohol Problems in the Emergency Department: A Systematic Review.” Academic
Emergency Medicine. June 2002; 9: 627-638.
6. Irvin CB, Wyer PC, Gerson LW, et al. for the SAEM Public Health and Education Task Force
Preventive Services Work Group. “Preventive Care in the Emergency Department Part II: Clinical
Preventive Services—An Emergency Medicine Evidence-based Review.” Academic Emergency
Medicine. Sept 2000; 7: 1042-1054.
7. Whitlock EP, Polen MR, Green CA, Orleans CT, and Klein J. “Behavioral Counseling
Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the
Evidence for the U.S. Preventive Services Task Force.” Annals of Internal Medicine. 2004; 140(7):
557-568.
8. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 3rd edition: Periodic
Updates. Screening and behavioral counseling interventions in primary care to reduce alcohol
misuse. Baltimore, MD. 2004.
Assessment and Counseling for Depression
Depression has become fairly common in primary care ranging in prevalence from 5 to 13% and
from 6 to 9% in older adults.1-2 The prevalence of depression in those patients with one or more
chronic illnesses is much higher. Up to 50% of depression is undiagnosed.1 The World Health
Organization has identified major depression as the fourth leading cause of worldwide disease in
1990 causing more disability than either ischemic heart disease or cerebrovascular disease.3 The US
Preventive Services Task Force found sufficient evidence to recommend screening adults for
depression in clinical practices that have systems in place to assure accurate diagnosis, effective
treatment, and follow-up.2 They suggest there is evidence that screening programs improve health
outcomes.
Several depression screening questionnaires are available; however, Gundersen recommends the use
of the following strategy to screen for depression in the primary care setting. A simple two question
36
Revised January 2014
screen, 3 the Patient Health Questionnaire (PHQ-2), developed by Whooly4 may be used with a
majority of patients. If the patient answers half or nearly all to either of these questions, it is
recommended the patient complete a nine-item version the PHQ-9,5 the Beck Depression Inventory
(BDI),6 or a Zung Self-Rating Depression Scale (SDS).7 If the patient scores a 10 or more or the
PHQ-9, they should be assessed for suicide risk and consideration for clinical treatment.
Some patients with “false positive” results on screening may have dysthmyia or subsyndromal
depressive disorders such as anxiety disorder. The finding of a positive screen requires further
diagnostic questioning by the clinician to establish an appropriate diagnosis and initiate a plan for
treatment and follow-up.
References Cited:
1. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care.
Arch Fam Med 1995;4:99-105.
2. U.S. Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Services
Task Force Recommendation Statement. Ann Intern Med 2009;151:784-792.
3. Murray CJ, Lopez AD. Global Burden of Disease. Cambridge, MA: Harvard University Press;
1996.
4. Whooley, Mary A., Avins, Andrew L., Miranda, Jeanne, Browner, Warren S., Case-Finding
Instrument for Depression: Two Questions Are as Good as many, Journal of General Internal
Medicine 1997; 12:439-445.
5. Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD:
the PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 1737-1744
6. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory:
twenty-five years of evaluation. Clin Psychol Rev 1988;8:77-100.
7. Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.
On how many days during the past month, have you been bothered by feeling down, depressed or hopeless? (never,
few, half, nearly all)
On how many days during the past month, have you been bothered by little interest or pleasure in doing things?
(never, few, half, nearly all)
3
37
Revised January 2014
Injury Prevention Counseling
Clinicians should regularly urge their patients to use the following safety precautions:




To use safety belts (lap and shoulder safety belts) whenever driving or riding in an
automobile.
Parents should be urged to use proper child safety seats for their infants and children.
Those who operate or ride on bicycles or motorcycles should be counseled to wear safety
helmets.
All patients should be counseled regarding the dangers of operating a motor vehicle while
under the influence of alcohol or other drugs, as well as on the risks of riding in a vehicle
operated by someone who is under the influence of these substances. (See above section on
alcohol counseling.)
Homeowners should be advised of safety precautions within the home environment including:
 To install smoke detectors in appropriate locations and to test the devices periodically (at
least twice each year) to ensure proper operation.
 Hot water heaters should be set at 120o F.
 Firearms should be kept unloaded in a locked compartment.
 Elderly patients or those responsible for older persons should be advised to inspect the
home for adequate lighting, to remove or repair floor structures that predispose to tripping,
and to install handrails and traction strips in stairways and bathtubs.
 Clinicians caring for older persons should periodically test visual acuity, counsel patients with
medical conditions that affect mobility, and monitor the use of drugs associated with falls.
Older patients who lack medical contraindications should be counseled to engage in exercise
programs to maintain and improve mobility and flexibility.
The American Academy of Pediatrics published guidelines on child passenger safety in 2011.1 A
change from previous recommendations is that infants/toddlers should face the rear until 2 years of
age instead of the previous recommendation of 20 pounds or 1 year of age. Children under the age
of 12 should always ride in the back seat.
38
Revised January 2014
Types of Car Safety Seats at a Glance1
Age Group
Infants/Toddlers
Type of
Seat
Toddlers/Preschoolers
Infant seats and
rear-facing
convertible
seats
Convertible
seats and
forward-facing
seats
with harnesses
School-aged children
Booster seats
Older children
Seat belts
General Guidelines
All infants and toddlers should ride in a Rear-Facing
Car Safety Seat until they are 2 years of age or until
they reach the highest weight or height allowed by
their car safety seat’s manufacturer.
All children 2 years or older, or those younger than 2
years who have outgrown the rear-facing weight or
height limit for their car safety seat, should use a
Forward-Facing Car Safety Seat with a harness for
as long as possible, up to the highest weight or height
allowed by their car safety seat’s manufacturer.
All children whose weight or height is above the
forward-facing limit for their car safety seat should use
a Belt-Positioning Booster Seat until the vehicle seat
belt fits properly, typically when they have reached 4
feet 9 inches in height and are between 8 and 12 years
of age.
When children are old enough and large enough to use
the vehicle seat belt alone, they should always use Lap
and Shoulder Seat Belts for optimal protection.
All children younger than 13 years should be
restrained in the Rear Seats of vehicles for optimal
protection.
The optimal frequency for counseling patients about motor vehicle injury has not been determined
and is left to clinical discretion. The U.S. Preventive Services Task Force found insufficient evidence
of the effectiveness of clinician counseling on improved rates of proper use of seat belt use.2 Nonethe-less, statements to patients about this issue can support community-based legislation. Counseling
is most important for those at increased risk of motor vehicle injury, such as young adults, persons
who use alcohol or other drugs, and patients with medical conditions that may impair motor vehicle
safety.
The U. S. Preventive Services Task Force released their review of data in 2010 regarding counseling
to prevent falling in older adults.3 Guidelines are expected to be released in 2011. The findings
suggest that exercise, physical therapy and vitamin D supplementation reduce the risk for falling
among community-dwelling older adults, and no clinical harms in recommending them. Trials on
vitamin D supplementation were not designed to address long-term adverse effects. The need to
prevent household or environmental injuries should be discussed regularly with patients, especially
those who are at increased risk for certain types of injuries. The optimal frequency for such
counseling has not been determined, however, and is left to clinical discretion.
39
Revised January 2014
The U. S. Preventive Services Task Force found insufficient evidence to recommend for or against
routine counseling by primary care clinicians to prevent skin cancer.3
References Cited:
1. Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics 2011;
127: e1050-e1066
2. U.S. Preventive Services Task Force Counseling about proper use of motor vehicle occupant
restraints and avoidance of alcohol use to prevent injury: U. S. Preventive Services Task Force
Recommendation Statement. 2007. Available at:
http://www.uspreventiveservicestaskforce.org/uspstf/uspsmvin.htm assessed on 4/1/11
3. U.S. Preventive Services Task Force Counseling to prevent skin cancer, 2003. Available at:
http://www.uspreventiveservicestaskforce.org/uspstf/uspsskco.htm assessed on 4/1/11
Sexual Behavior Assessment and Counseling
Clinicians should obtain a detailed sexual history from all adult patients. For sexually active patients,
the interview should include a discussion of the sexual practices and feelings of the patient and
partner, as well as an assessment of the level of patient concern about the risk of unintended
pregnancy. Based on this information, the clinician should provide appropriate counseling on the
level of risk associated with the patient’s current contraceptive techniques and, when indicated,
available alternatives for more effective prevention.
Sexually active patients should receive complete information on their risk for acquiring sexually
transmitted infections (STIs). They should be advised that abstaining from sex or maintaining a
mutually faithful monogamous sexual relationship with a partner known to be uninfected are the
most effective strategies to prevent infections with HIV or other sexually transmitted infections.
Patients should be offered testing in accordance with recommendations on screening for syphilis,
gonorrhea, chlamydia, genital herpes, hepatitis B, and infection with HIV. The optimal frequency of
counseling to prevent unintended pregnancy and sexually transmitted diseases has not been
determined and is left to clinical discretion.
Clinicians should also recommend patients under the age of 26 years receive the human papilloma
vaccination (see below Immunization: HPV) as it has been shown to prevent some types of genital
warts that may lead to cervical cancer.
The U. S. Preventive Services Task Force released its guidelines for counseling in 2008. They found
sufficient evidence for high-intensity behavioral counseling for all sexually active adults at increased
risk for sexually transmitted infections.1 They found insufficient evidence to counsel non-sexually
active adults not at increased risk for STI’s.
References Cited:
1. U.S. Preventive Services Task Force. Behavioral counseling to prevent sexually transmitted
infections: U. S. Preventive Services Task Force Recommendation Statement. Ann Intern Med
2008;149:491-496.
40
Revised January 2014
IMMUNIZATIONS
Immunizations: Tetanus, Diphtheria and Pertussis
Recommendation:
A tetanus diphtheria pertussis booster should be given every 10 years for adults over the age of 18
after completion of the primary series. Tdap is preferred over Td for wound management in adults
aged 19 years and older who have not received Tdap previously. It is recommended that all adults
regardless of age receive a single dose of Tdap to replace the single dose of Td for booster
immunization against tetanus, diphtheria, and pertussis. Tdap can be given no matter when Td was
last received. Adults anticipating close contact with an infant should be vaccinated at least 2 weeks
before anticipated contact. Expectant mothers should receive Tdap during each pregnancy,
preferably at 27 through 36 weeks, irrespective of past history of receiving Tdap.
A primary series for adults not previously vaccinated is three doses of a tetanus containing vaccine
with Tdap as the first dose: the first two doses administered at least four weeks apart and the third
dose, 6-12 months after the second dose. Tdap or Td may be given with other vaccines. Those
traveling to countries of the Caribbean, Latin American and Eastern Europe should be fully
vaccinated prior to travel as diphtheria remains endemic in these countries.
Adults that have hypersensitivity to any component of the vaccine, including Thimersol, or a history
of a systemic allergy or neurologic reaction to a previous dose should not receive the vaccination.
Disease and basis for recommendation:
Tetanus, a noncommunicable disease of the nervous system, is caused by bacteria entering the body
through a break in the skin. Early symptoms of tetanus include lockjaw, stiffness of the neck and
abdomen, and difficulty swallowing. Later symptoms include fever, elevated blood pressure, and
severe muscle spasms. Death results in 11% of all cases of tetanus. The reported incidence of
tetanus has declined substantially since the mid-1940s, when tetanus toxoid (TT) became available
for widespread use. The tetanus surveillance system documented 14 cases in 2003 compared to 560
cases in 1947 (the year reporting began.)1 In 2010, there were 8 cases of tetanus, down from an
average of 18 to 41 cases in the previous 5 years.2 Wherever aggressive immunization practices exist,
the rate of tetanus is low. Furthermore, serologic studies demonstrate a strong correlation between
vaccination coverage and immunity to tetanus among children. Antibody levels decline over time,
with the lowest rates among older adults. In a national survey published in 2002, 69% of adults age
70 and older lacked protective levels of tetanus antibodies.3
Diphtheria is a disease caused by a bacteria Corynebacterium diphtheriae, that is most commonly
transmitted from person to person through respiratory mechanisms. The symptoms of diphtheria
include a respiratory tract illness characterized by a sore throat, low-grade fever, and thick coating in
the nose, throat, or airway. It is diagnosed by isolation of C diphtheriae from a clinical specimen. It
has a 5-10% mortality rate. In the 1920s, there were between 100,000 and 200,000 cases per year,
and 13,000 to 15,000 deaths annually. Fortunately, since the introduction of immunization practices,
the rate has declined significantly. From 1980-2002, 54 cases were reported in the United States.
There have been no reported cases of C diphtheriae over the past 6 years.2 Although cases of
diphtheria are rare, it appears that C diphtheriae continues to circulate in the areas that were endemic
to outbreaks, and other areas of the world continue to have outbreaks of diphtheria.
41
Revised January 2014
Pertussis, also known as whopping cough, is a bacterial respiratory infection which is characterized
by severe spasms of coughing. Before the introduction of the vaccination in the 1940s, pertussis was
a major cause of illness and death among infants. With the introduction of the pertussis vaccination
in the 1940s, case reports of persussis decreased more than 99%. An increasing number of cases of
pertussis have been reported to the CDC since the 1980s, especially among adolescents aged 10-19
years and adults. In 2004, US adults ages 19-64 accounted for 27% of the reported pertussis cases.
The United States has experienced substantial increases in reported pertussis cases over the past
several years. Provisional case counts for 2012 have surpassed the last peak year, 2010, with 41,880
pertussis cases and 14 deaths in infants aged <12 months. 4 To slow the spread of pertussis to adults
with waning immunity, the Advisory Committee on Immunization Practices recommended routine
use of a single dose of Tdap regardless of interval since the last tetanus- or diphtheria-toxoid
containing vaccine.5
Other Organizations’ Recommendations:
The Advisory Committee on Immunization Practices (ACIP) recommends a single Tdap dose for
persons who have completed the recommended childhood diphtheria and tetanus toxoids and
pertussis/diphtheria and tetanus toxoids and acellular pertussis (DTP/DTaP) vaccination series. 5
ACIP recommends that pertussis vaccination, when indicated, should not be delayed and that Tdap
should be administered regardless of interval since the last tetanus or diphtheria toxoid-containing
vaccine. ACIP concluded that while longer intervals between Td and Tdap vaccination could
decrease the occurrence of local reactions, the benefits of protection against pertussis outweigh the
potential risk for adverse events. After receipt of Tdap, persons should continue to receive Td for
routine booster immunization against tetanus and diphtheria, according to previously published
guidelines. ACIP believes that the actual burden of pertussis in adults aged 65 years and older likely
is at least 100 times greater than that reported. In February 2012, ACIP recommended Tdap for all
adults aged 65 years and older.6
The ACIP provides additional information regarding vaccination of pregnant women.7 Very young
infants are dependent solely on maternal antibodies and lack the ability to mount a cell-mediated
response. High levels of maternal antibodies in the first weeks after birth likely confer protection
and might prevent pertussis or modify disease severity in the infant. Because antibody levels wane
substantially during the first year after vaccination, ACIP concluded a single dose of Tdap at one
pregnancy would be insufficient to provide protection for subsequent pregnancies. Tdap may be
administered any time during pregnancy, but vaccination during the third trimester would provide
the highest concentration of maternal antibodies to be transferred closer to birth. For women not
previously vaccinated with Tdap, if Tdap is not administered during pregnancy, Tdap should be
administered immediately postpartum.
The US Preventive Services Task Force has agreed to not duplicate efforts and refers all readers to
the ACIP.
42
Revised January 2014
References cited:
1. Centers for Disease Control and Prevention. Summary of notifiable diseases, United States, 1990.
MMWR 1991;39(No. 53):55-61.
2. Centers for Disease Control and Prevention. Notifiable diseases and mortality tables. MMWR
2011;59:1704-1717.
3. McQuillan GM, Kruszon-Moran D, Deforest A, et al. Serologic immunity to diphtheria and
tetanus in the United States. Ann Intern Med. 2002;136:660-6.
4. National Center for Health Statistics. Health, United States, 2010: With Special Feature on Death
and Dying. Hyattsville, MD. 2011.
5. Centers for Disease Control and Prevention. Updated Recommendations for Use of Tetanus
Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine from the Advisory
Committee on Immunization Practices, 2010. MMWR 2010;60(01):13-15. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm Accessed on 5/22/13.
6. Centers for Disease Control and Prevention. Updated Recommendations for Use of Tetanus
Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65
Years and Older — Advisory Committee on Immunization Practices (ACIP), 2012. MMWR 2012;
61(25);468-470. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6125a4.htm accessed on 5/22/13.
7. Centers for Disease Control and Prevention. Updated Recommendations for Use of Tetanus
Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women —
Advisory Committee on Immunization Practices (ACIP), 2012. MMWR 2013; 62(07);131-135.
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm accessed on
5/22/13.
Approved May 22, 2013.
Immunizations: Influenza
Recommendation:
Influenza vaccine should be administered yearly to all adults ages 18 and older.
Additionally, those at highest risk of influenza-related complications should continue to be a special
focus of vaccination efforts. These include:
•
American Indian/Alaska natives,
•
Adults with morbid obesity (BMI >40),
•
Adults less than 50 years of age that reside in chronic care facilities,
•
Persons suffering from chronic cardiovascular or pulmonary or respiratory disorders,
metabolic disease, hemoglobinopathies, immunosuppression, or renal dysfunction,
•
Adults with an increased risk of aspiration,
•
Pregnant women regardless of their trimester of pregnancy during influenza season,
•
Persons living with high risk persons,
•
Those with occupational risks including health care providers, adults who handle respiratory
secretions, or people who work commonly with the public such as teachers should also be
vaccinated.1-2
43
Revised January 2014
If a shortage of vaccine in the community exists, influenza vaccination should focus on the above
high-risk individuals.
Persons who are not at high risk for severe influenza complications and who are known to have
experienced Guillian-Barre Syndrome (GBS) within 6 weeks of receipt of an influenza vaccine
generally should not be vaccinated. Physicians should discuss prompt treatment of influenza with
antivirals with this population.
Persons at risk for severe illness from influenza and who have severe egg allergies should be
evaluated by an allergist to determine safety of administering the vaccine. The majority of patients
with egg allergies would benefit from being vaccinated against influenza.
LAIV is indicated for 18-49 year olds.
Disease and basis for recommendation:
Influenza, also known as the flu, is a contagious disease that is caused by the influenza virus,
typically Influenza A or B. There are several subtypes; the subtype circulating varies from year-toyear. Immunity to the surface antigen reduces the likelihood and severity of disease if infection
occurs; however, antibody against one type of virus subtype provides limited to no protection
against another. Frequent combinations of subtypes are included in each year’s vaccine. In 2010, the
H1N1 antigen was added to the vaccine mixture.
The influenza virus attacks the respiratory tract in humans (nose, throat and lungs), and is different
from a cold. Symptoms include: fever, headache, tiredness, dry cough, sore throat, nasal congestion,
and body aches. Influenza illness typically resolves after a few days for a majority of people,
although some symptoms can persist for two or more weeks. Influenza can worsen underlying
medical conditions such as respiratory or cardiac disease. The risk for complications, hospitalizations
and death from influenza are higher among persons aged > 65 years, young children, and persons of
any age with certain underlying health conditions, as described above.
The estimated rates of influenza-associated pulmonary and circulatory deaths per 100,000 persons in
1999 were 0.4-0.6 among persons aged 0-49 years, 7.5 among persons 50-64 years, and 98.3 among
persons over age 65 years. The influenza season begins in late September and ends near the end of
May, usually peaking in mid-to-late February. True incident numbers are difficult to obtain since a
majority of cases go unreported. In 2002/2003, 11% of specimens for influenza virus were positive
for influenza. Nationally, influenza morbidity as reported by US sentinel physicians exceeded the
baseline level of 1.9% during the peak weeks of the outbreak averaging 3.2% of physician visits for
influenza-like illnesses.3
Other Organizations’ Recommendations:
The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza
vaccinations to all persons aged > 6 months, regardless of preexisting medical conditions.
Furthermore, any person > 6 months who is at increased risk for complications from influenza may
be vaccinated yearly, and healthy persons aged 4-49 years without high risk conditions may receive
either the inactivated vaccine or the intranasally administered influenza vaccine.1 The U.S. Preventive
Services Task Force and most other organizations have agreed to not duplicate efforts and refer all
readers to the ACIP.
44
Revised January 2014
References cited:
1. Centers for Disease Control and Prevention. Prevention and Control of Influenza with Vaccines:
Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR
2010;59(No. RR-#8):1-66.
2. Centers for Disease Control and Prevention. Influenza vaccination of health-care personnel:
recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC)
and the Advisory Committee on Immunization Practices (ACIP). MMWR 2006: 55(RR02);1-16.
3 Centers for Disease Control and Prevention. 2010-2011 Influenza Season Week 11 ending March
19, 2011 Available at: http://www.cdc.gov/flu/weekly/ accessed on 3/30/2011.
Approved May 22, 2013.
Immunizations: Pneumococcal Pneumonia
Recommendation:
Pneumococcal vaccination should be provided once to all persons age 65 years and older.
Additionally, those younger than 65 years with the following medical conditions should be
vaccinated:
• chronic disorders of the pulmonary system including asthma, allergies, chronic bronchitis,
emphysema, cystic fibrosis, recurrent pneumonia, tuberculosis, pulmonary edema, lung
cancer, history of ARDS, Pneumoconiosis, interstitial lung disease, pulmonary edema
• cigarette smoking
• cardiovascular diseases including coronary artery disease, ischemic heart disease,
cardiomyopathy, hypertensive heart disease, heart failure, cor pulmonale, cardiac
dysrhythmias, endocarditis, cardiomegaly, myocarditis, valvular heart disease, stroke,
cerebrovascular disease, peripheral arterial disease
• diabetes
• chronic liver diseases including, hepatitis, fatty liver disease, hemochromatosis, primary
biliary cirrhosis, primary sclerosing cholangitis, cirrhosis
• chronic renal failure or nephrotic syndrome,
• functional or anatomic asplenia resulting from sickle cell disease, splenectomy, congenital or
acquired asplenia
• cochlear implants
• cerebrospinal fluid leak
• immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia,
lymphoma, multiple myeloma, Hodgkin disease, generalized malignancy, and organ or bone
marrow transplantation),
• chemotherapy with alkylating agents, antimetabolites, or long-term corticosteroids, and
• residents of nursing homes and other long-term care facilities.
Native American and Alaska Native populations should only be vaccinated at ages < 65 if they are at
increased risk with any of the above conditions.
The total duration of antibody protection from pneumococcal vaccination is unknown. Elevated
titers appear to persist in adults for at least 5 years after immunization, but in some persons, they
45
Revised January 2014
may fall to prevaccination levels within 10 years. The CDC recommends a maximum of two doses
of the vaccine be given in a patient’s lifetime. Persons vaccinated before age 65 should receive a
second dose at age 65 years or later if at least 5 years have passed since the previous dose.
Adults that have had a severe reaction to the pneumococcal vaccine before or are allergic to phenol
should not be given a pneumococcal vaccine. Additionally, if the patient has an acute febrile
infection, the immunization should be delayed until the symptoms have subsided.
Disease and basis for recommendation:
The pneumococcal vaccine protects against the Streptococcus pneumoniae, a gram-positive
bacterium. These bacteria can cause not only pneumonia, but also bacteremia and meningitis.
Pneumococcal disease is a significant cause of morbidity and mortality in the United States. S.
pneumoniae accounts for 20% to 60% of all community-acquired bacterial pneumonias (CAP) in
adults.1-2 An estimated 43,500 cases and 5,000 deaths occurred among persons of all ages in 2009.2
The symptoms of pneumococcal pneumonia develop abruptly and typically include the following: a
single episode of chills followed by fever; chest pain (and occasionally severe abdominal pain if
pneumonia is in the lower lobes of the lung) on the side of the pneumonia; shortness of breath;
rapid breathing and heart beat; cough – may be dry at first, but it eventually produces sputum; and
occasionally nausea, vomiting or muscle aches. Symptoms in the elderly may come on more slowly
and they may have fewer or different symptoms than younger patients. Elderly patients may also
exhibit confusion, lethargy, and general deterioration.
The risks for complications, hospitalizations, and death from pneumococcus pneumonia are higher
among persons aged >65 years, persons in certain living arrangements or geographical areas, and
among persons of any age with certain underlying health conditions, as described above. Respiratory
failure, acute respiratory distress syndrome (ARDS), is one of the main causes of death in patients
with pneumococcal pneumonia. Bacteremia is the most common complication of pneumococcal
infection, but rarely does it spread to other sites.
Pneumococcal disease is a constant threat (i.e., does not occur in a “season” like influenza). The risk
of getting pneumococcal disease increases after age 40, doubling after age 60. In recent years,
pneumococcal infections have accounted for >100,000 hospitalizations for pneumonia, >60,000
cases of bacteremia and other forms of invasive disease, and about 5000 deaths.3 In 2009, >84% of
these cases and nearly all deaths occurred among people aged >65 years.2,4 The emergence of drugresistant strains underscores the importance of preventing pneumococcal disease by vaccination.
Other Organizations’ Recommendations:
Gundersen follows the recommendations of the Advisory Committee on Immunization Practices
and are stated above.2 Furthermore, the ACIP recommendations on the use of pneumococcal
vaccines concurs with the recommendations of the Infectious Diseases Society of America (IDSA).5
The US Preventive Services Task Force has agreed to not duplicate efforts and refer all readers to
the ACIP.
References cited:
1. Centers for Disease Control and Prevention. Prevention of pneumococcal disease:
recommendations of the Advisory Committee on Immunization Practices. MMWR 1997;46 (RR8):1-24.
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Revised January 2014
2. Centers for Disease Control and Prevention. Updated recommendations for prevention of
invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide
vaccine (PPSV23) MMWR 2010; 59:1102-1106.
3. Centers for Disease Control and Prevention. Active Bacterial Core Surveillance (ABCs) Report:
group B Streptococcus, 2008: Emerging Infections Program Network Available at:
http://www.cdc.gov/abcs/reports-findings/survreports/gbs08.pdf Accessed 3/31/2011.
4. Centers for Disease Control and Prevention, Active Bacterial Core Surveillance (ABCs) Report:
Emerging Infections Program Network. Streptococcus pneumoniae, provisional-2009. Atlanta, GA:
US Department of Health and Human Services, CDC; 2010. Available at
http://www.cdc.gov/abcs/reports-findings/survreports/spneu09.pdf Accessed 3/31/2011
5. Infectious Disease Society of America Vaccine information. Pneumococcal Disease. Available at:
http://www.idsociety.org/Content.aspx?id=6346 Accessed 3/31/2011.
Approved 2/12/13
Immunization: Herpes Zoster
Recommendation:
The zoster vaccine is recommended for all adults aged 60 years and older who have no
contraindications.
Patients who report a previous episode of zoster or who have chronic medical conditions can be
safely vaccinated. It is not necessary to determine prior history of varicella (chickenpox) or to
conduct serological testing for varicella immunity. The zoster vaccine may be given at the same time
as the influenza, Td, Tdap, or pneumococcal polysaccharide vaccine.
Zoster vaccine is contraindicated for persons who have a history of anaphylactic reaction to any
component of the vaccine, including gelatin and neomycin. (A history of contract dermatitis to
neomycin is not a contraindication for receiving zoster vaccine.) Zoster vaccine should not be given
to persons with a primary or acquired immunodeficiency including:
• Persons with leukemia, lymphomas or malignant neoplasms affecting the bone marrow or
lymphatic system,
• Persons with AIDS or other clinical manifestations of HIV,
• Persons on immunosuppressive therapy, including high-dose corticosteroids lasting two
weeks or more,
• Persons with clinical or laboratory evidence of other unspecified cellular immunodeficiency.
However, persons with impaired humoral immunity (e.g., hypogammaglobulinemia or
dysgammaglobulinemia) can receive zoster vaccine,
• Persons undergoing hematopoietic stem cell transplantation, and
• Persons receiving recombinant human immune mediators and immune modulators,
especially the antitumor necrosis factor agents adalimumab, infliximab, and etanercept.
Disease and basis for recommendation:
Zoster is a localized, generally painful cutaneous eruption that occurs most frequently among older
adults and immunocompromised persons. It is caused by reactivation of latent varicella zoster virus
(VZV) decades after initial VZV infection is established. Approximately one in three persons will
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Revised January 2014
develop zoster during their lifetime, resulting in an estimated 1 million episodes in the United States
annually. A common complication of zoster is post herpetic neuralgia (PHN), a chronic, often
debilitating pain condition that can last months or even years. The risk for PHN in patients with
zoster is 10%–18%. Another complication of zoster is eye involvement, which occurs in 10%–25%
of zoster episodes and can result in prolonged or permanent pain, facial scarring, and loss of vision.
Approximately 3% of patients with zoster are hospitalized; many of these episodes involved persons
with one or more immunocompromising conditions. Deaths attributable to zoster are uncommon
among persons who are not immunocompromised.1
The zoster vaccine was licensed in the United States as a live, attenuated VZV, the same strain used
in the varicella vaccines. Zoster vaccine should be administered as a single 0.65 mL dose
subcutaneously in the deltoid region of the upper arm. No booster is indicated at this time. In
clinical trials, the vaccine reduced the risk of developing zoster by 51%.
Other Organizations’ Recommendations:
The Advisory Committee on Immunization Practices (ACIP) released their recommendations for
prevention and control of herpes zoster.1 Recommendations for vaccination are for all adults aged
60 years and older who have no contraindications, including patients who report a previous episode
of zoster or who have chronic medical conditions.
The U.S. Preventive Services Task Force and most other organizations have agreed to not duplicate
efforts and refer all readers to the ACIP.
References cited:
1. Centers for Disease Control and Prevention. Prevention of Herpes Zoster. Recommendations of
the Advisory Committee on Immunization Practices (ACIP) MMWR 2008;57(RR-5):1-30
Approved on 3/13/13
Immunizations: Human Papillomavirus
Recommendation:
Females ages 18 –26 who not been vaccinated previously or who have not completed the full
vaccine series for human papillomavirus (HPV) should receive the HPV series.
The 3-dose series of HPV4 may also be given to males, ages 18-26 years to reduce their likelihood of
acquiring genital warts
Routine vaccination (starting as young as age 9 for both males and females) consists of three doses,
the second dose two months after the first, and the third dose six months after the first dose. Ideally
the vaccine should be administered before potential exposure to HPV through sexual contact with
someone infected with HPV. If the HPV vaccine schedule is interrupted, the vaccine series does not
need to be restarted.
Disease and basis for recommendation:
Human papillomavirus is the most common sexually transmitted disease in the United States. The
Centers for Disease Control and Prevention (CDC) estimates 6.2 million persons are newly infected
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Revised January 2014
each year.1 Approximately 100 HPV types have been identified, over 40 of which infect the genital
area. A majority of infections cause no clinical symptoms. HPV serotypes 16 and 18, however are
responsible for 70% of cervical cancer. Furthermore, serotypes 6 and 11 are strongly associated with
genital warts. Clinical trials including over 20,000 subjects have demonstrated the safety and efficacy
of the vaccine, with a 93-100% reduction in cervical dysplasia and/or cancer related to vaccine
serotypes.1
Two vaccinations have been licensed for use in the United States. The first, a quadrivalent vaccine,
HPV4 is directed to HPV 16 and 18 (oncogenic) and HPV 6 and 11 (non-oncogenic.) This was
licensed in 2006 for use with females. A second, bivalent HPV vaccine HPV2 directed against HPV
16 and 18 (oncogenic) was licensed in 2009 for females. Both vaccinations have been shown to be
equally safe and efficacious. In 2009 the HPV4 vaccine was also licensed for use with males to
prevent genital warts.
Other Organizations’ Recommendations:
The Advisory Committee on Immunization Practices (ACIP) HPV vaccine workgroup released their
recommendations in March, 2007. In these, they recommend the quadrivalent vaccination HPV4
(Gardasil) among females (aged 9-26 years) in a 3-dose series beginning at age 9, with the second
and third doses 2 and 6 months after the first dose. Catch-up vaccination is recommended for
females aged 13-26 years who have not been previously vaccinated. In 2009, the Food and Drug
Administration (FDA) licensed the bivalent HPV2 (Cervavix), for use in females aged 10 through 25
years.2 The ACIP released updated recommendations that encourage all females aged 11or 12 to be
vaccinated with 3 doses of either HPV2 or HPV4. For the adult female not previously vaccinated,
either vaccination type will provide protection and should be administered in the 3 dose series (again
with the second and third doses 2 and 6 months after the first dose.) The HPV4 also provides
protection from genital warts. In December of 2010, the U.S. Food and Drug Administration
approved the HPV4 vaccine for the prevention of anal cancer.
Also in 2009, the FDA licensed the HPV4 vaccine for use in males aged 9 to 26 years for prevention
of genital warts.3 The 3-dose series of HPV4 was most effective when given before exposure to HPV
through sexual contact.
The U.S. Preventive Services Task Force and most other organizations have agreed to not duplicate
efforts and refer all readers to the ACIP.
References cited:
1. Centers for Disease Control and Prevention. Quadrivalent human papillomavirus vaccine.
Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2007 MMWR.
56(RR02):1-24.
2. Centers for Disease Control and Prevention. FDA Licensure of Bivalent Human Papillomavirus
Vaccine (HPV2, Cervarix) for Use in Females and Updated HPV Vaccination Recommendations
from the Advisory Committee on Immunization Practices (ACIP). MMWR 2010; 59:626-629
3. Centers for Disease Control and Prevention. FDA Licensure of Quadrivalent Human
Papillomavirus Vaccine (HPV4, Gardasil) for Use in Males and Guidance from the Advisory
Committee on Immunization Practices (ACIP) MMWR 2010;59:630-632
Approved 2/1/13
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Revised January 2014
Immunization: Meningococcal Meningitis
Recommendation:
Adults ages 18 –21 at increased risk for meningococcal disease and have not been vaccinated
previously for meningococcal disease should receive a single dose of the meningococcal conjugate
vaccine; administered intramuscularly. If previously vaccinated at age 11 to 12 years of age, and not
given a booster, then a booster vaccine should be provided any time after the sixteenth birthday.
The following populations are at increased risk for meningococcal disease:
• College freshmen living in dormitories,
• Military recruit,
• Persons who travel to or reside in countries in which N. meningitdis is hyperendemic or
epidemic,
• Persons who have terminal complement component deficiencies, and
• Persons who have anatomic or functional asplenia.
A 2-dose series is recommended for adults with anatomic or functional asplenia, persistent
complement component deficiencies or HIV infection.
Routine vaccination of healthy persons who are not at increased risk to meningococcal disease is not
recommended after age 21 years. Young adults are at more risk for meningococcal meningitis and
should be vaccinated at college entry. The vaccine is a single dose. Protection is expected to last
three to five years, which is the length of time most adults are away at college. Meningococcal
conjugate vaccine should be administered intramuscularly; however, revaccination is not necessary
when administered subcutaneously.
Disease and basis for recommendation:
Meningococcal disease is an acute, potentially life-threatening illness caused by the bacteria Neisseria
meningitides.1 Even in the absence of a routine vaccination program, meningococcal disease is
relatively rare in the United States, with 2 to 3,000 cases reported each year. A total of 749 cases
from all serotypes were reported to the Centers for Disease Control in 2010.2 Although incidence is
low, more cases occur among persons 16 to 23 years of age. Meningococcus causes severe blood
infections or meningitis, a swelling of the brain and spinal cord. Symptoms may include high fever,
headache, stiff neck, nausea and vomiting. Meningococcus can be a very serious illness because it
can progress very quickly and its symptoms are often mistaken for other less serious illnesses.
The risk for meningococcal disease is higher among college students living in dormitories, however,
those college students not living in dormitories were at no higher risk than non-college students of
similar age.1
The meningococcal conjugate vaccine was licensed in January 2005, and is believed to have a longer
duration of immunity than the polyscaccharide vaccine. A quadrivalent meningococcal conjugate
vaccine was also licensed in February of 2010. Both vaccines protect against serogroups A, C, Y, W135. They do not protect against serogroup B, another common serogroup that may still cause
disease in the vaccinated. There is no licensed vaccine to protect against serogroup B.
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Revised January 2014
Other Organizations’ Recommendations:
The Advisory Committee on Immunization Practices (ACIP) released their recommendations for
prevention and control of meningococcal disease in 2005.1 Recommendations for vaccination are
for adolescents at ages 11-12 years. Because of missed vaccination possibilities, and the feasibility
constraints of targeting freshmen in dormitories, it is recommended that adults age 18-21 be
vaccinated.
In 2010, the ACIP updated their recommendations to include a booster dose for adolescents
beginning at age 16.3 They found that since 2000, the incidence of meningococcal disease was at
historic lows. But the peak disease among persons aged 18 years has persisted, even after routine
vaccination was begun in 2005.3 An examination of immunity levels suggests a waning after 5 years.
Therefore the ACIP recommends a booster dose of vaccine at age 16. For adults age 18-21 not
previously vaccinated or vaccinated prior to age 16 and not given a booster, should receive a second
dose of the meningococcal conjugate vaccine.
References cited:
1. Centers for Disease Control and Prevention. Prevention and Control of Meningococcal Disease
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR
2005;54(No: RR-7):1-12
2. Centers for Disease Control and Prevention. Notifiable diseases and mortality tables. MMWR
2011;59:1704-1717.
3. Centers for Disease Control and Prevention. Updated Recommendations for Use of
Meningococcal Conjugate Vaccines --- Advisory Committee on Immunization Practices (ACIP),
2010. MMWR 2011;60:72-76.
Approved 3/13/13
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Revised January 2014