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## Complete Summary

#### GUIDELINE TITLE

Locally acquired mosquito-transmitted malaria: a guide for
investigations in the United States.

#### BIBLIOGRAPHIC SOURCE(S)

Centers for Disease Control and Prevention, Filler SJ, MacArthur JR,
Parise M, Wirtz R, Eliades MJ, Dasilva A, Steketee R. Locally acquired
mosquito-transmitted malaria: a guide for investigations in the United
States \[published erratum appears in MMWR Morb Mortal Wkly Rep 2006 Oct
6;55(39):1075\]. MMWR Recomm Rep 2006 Sep 8;55(RR-13):1-9. \[20
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16960552)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Locally acquired mosquito-transmitted malaria

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention

#### CLINICAL SPECIALTY

Family Practice\
Infectious Diseases\
Internal Medicine\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Hospitals\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

To describe the steps that should be taken to:

-   Investigate a case of malaria that has been potentially acquired
    locally

-   Prevent a small focus of malaria cases from becoming a source of
    sustained transmission

-   Inform clinicians regarding the process of an investigation so they
    can effectively address concerns and questions from patients

#### TARGET POPULATION

-   Individuals living in the United States with suspected locally
    acquired malaria

-   Individuals living in communities in the United States in which
    locally acquired mosquito-transmitted malaria is suspected

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Initial Investigation**

1.  Confirmation of cases of malaria

2.  Preliminary patient interviews

3.  Involvement of state health departments and Centers for Disease
    Control and Prevention (CDC)

**Epidemiologic Investigation**

1.  Confirmation that case definition has been met

2.  In-depth patient interview(s)

3.  Confirmation that all diagnosed cases of malaria have been reported

4.  Active case finding (of undiagnosed malaria)

5.  Community sensitization (including medical and nonmedical
    populations)

**Environmental Investigation**

1.  Site visits to patients\' homes

2.  Entomologic assessment

3.  Assessment of climatic conditions

4.  Investigation of possible airport malaria

**Laboratory Investigation**

1.  Species confirmation

2.  Performance of molecular techniques with assistance form CDC

**Other interventions**

1.  Determination that an outbreak is over

2.  Measures to prevent reestablishment of malaria

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Checklist for Investigations of Locally Acquired Mosquito-Transmitted
Malaria**

+-----------------------------------------------------------------------+
| +------------------------------+----------------------------------+   |
| | **Tasks for local health     |                                  |   |
| | departments**                |                                  |   |
| +------------------------------+----------------------------------+   |
| | Task A. Confirm case         | Task E. Conduct laboratory       |   |
| |                              | investigation                    |   |
| | -   Laboratory confirmation  |                                  |   |
| |                              | -   Species confirmation         |   |
| | -   Preliminary patient      |                                  |   |
| |     interview(s)             |     -   Use reference laboratory |   |
| |                              |         (i.e., state health      |   |
| | Task B. Initiate             |         department and CDC) as   |   |
| | Investigation                |         needed                   |   |
| |                              |                                  |   |
| | -   Involve state health     |     -   Perform polymerase chain |   |
| |     department               |         reaction test if slide   |   |
| |                              |         microscopy is            |   |
| | -   Contact with the Centers |         inconclusive             |   |
| |     for Disease Control and  |                                  |   |
| |     Prevention (CDC) can be  | -   Molecular techniques with    |   |
| |     initiated by the state   |     assistance from CDC          |   |
| |     health department        |                                  |   |
| |                              |     -   Link outbreak cases      |   |
| | Task C. Conduct              |                                  |   |
| | epidemiologic investigation  |     -   Investigate geographic   |   |
| |                              |         origin of strain         |   |
| | -   Case definition has been |                                  |   |
| |     met                      | Task F. Avoid potential pitfalls |   |
| |                              |                                  |   |
| |     -   Determined by blood  | -   Mass screening; low yield,   |   |
| |         smear                |     expensive and labor          |   |
| |                              |     intensive                    |   |
| | -   In-depth interviews with |                                  |   |
| |     patients                 |     -   Blood films              |   |
| |                              |                                  |   |
| | -   Case reporting           |     -   Serosurveys              |   |
| |                              |                                  |   |
| |     -   Confirm that         | -   Entomology resources         |   |
| |         laboratories and     |                                  |   |
| |         providers have       |     -   Trapping; data           |   |
| |         reported cases       |         frequently already       |   |
| |                              |         available                |   |
| | -   Active case finding      |                                  |   |
| |                              |     -   Vector control; unclear  |   |
| | -   Community sensitization  |         value                    |   |
| |                              |                                  |   |
| | Task D. Conduct              | Task G. Determine outbreak is    |   |
| | environmental investigation  | over                             |   |
| |                              |                                  |   |
| | -   Site visit to patients\' | -   No new cases identified for  |   |
| |     homes                    |     two completed parasite life  |   |
| |                              |     cycles (i.e.,  8 weeks)      |   |
| | -   Entomologic assessment   |                                  |   |
| |                              | Task H. Attempt to prevent       |   |
| |     -   Breeding habits and  | reestablishment of malaria       |   |
| |         vector surveillance  |                                  |   |
| |                              | -   Health-care availability for |   |
| | -   Assessment of climatic   |     immigrant and migrant        |   |
| |     conditions               |     workers                      |   |
| |                              |                                  |   |
| |     -   Use of temperature   | -   Personal protective          |   |
| |         and rainfall data to |     measures; wear proper        |   |
| |         predict viability of |     clothing (e.g., long-sleeved |   |
| |         competent vector     |     shirts and long trousers),   |   |
| |                              |     use N, N-diethyl-m-toluamide |   |
| | -   Airport malaria          |     (DEET)-based (DEET           |   |
| |                              |     concentration                |   |
| |     -   Assess distance of   |     [\<]{.underline}50%) insect  |   |
| |         patients\' homes     |     repellants, and avoid        |   |
| |         from airport         |     outdoor activities from dusk |   |
| |                              |     until dawn                   |   |
| +------------------------------+----------------------------------+   |
+=======================================================================+
+-----------------------------------------------------------------------+

**[Investigation]{.underline}**

**Case Confirmation**

When a case of malaria is suspected to have been locally acquired, the
initial step is to confirm the diagnosis. Individual hospitals might not
have extensive experience in microscopic parasitic diagnoses, but the
majority of state laboratories can assist in confirming diagnoses. For
states that do not maintain such expertise or that would like further
assistance, CDC can provide microscopy evaluation either by reviewing
the slides or (in a near-real-time manner) through telediagnosis
(submission of digital images through the Internet at
<http://www.dpd.cdc.gov/dpdx>). The diagnosis should be confirmed in a
timely manner to ensure that proper treatment is administered and that
appropriate measures are initiated to prevent continued transmission.
CDC also offers a confirmatory polymerase chain reaction (PCR) test,
which is based on the amplification of a portion of the small subunit
rRNA gene (ssrRNA). PCR can provide a definitive parasite and species
diagnosis when these diagnoses cannot be determined upon microscopic
examination (e.g., cases in which the morphology of the parasites is
atypical).

**Preliminary Patient Interview**

The investigation should begin with a careful interview with the
patient, and risk factors for acquiring malaria should be explored
(i.e., recent travel to an area where malaria is endemic, a history of
previous malaria infection, recent blood transfusion or organ
transplant, or contaminated needle use). If no link can be made to these
risk factors, the index of suspicion for a locally acquired
mosquito-transmitted illness increases.

Even if one of the previously mentioned risk factors for malaria is
present, locally acquired mosquito-borne transmission is not ruled out.
The risk must be examined in the context of the species and the timing
of the infection. For example, a *Plasmodium falciparum* infection will
rarely present \>2 to 3 years after primary exposure. Therefore, a case
of *P. falciparum* identified with a remote travel history (\>3 years)
cannot easily be classified as an imported case. In contrast, an absence
of risk factors does not always imply local acquisition. *P. malariae*
has been reported to cause symptoms long after exposure, even up to 40
years later. Health departments can contact CDC\'s Malaria Hotline
(770-488-7788) for assistance with species-specific information and to
help determine whether local transmission should be considered.

**Initiation of Investigation**

After a case has been confirmed by blood smear and the history suggests
no alternative explanation, the full investigation of a locally acquired
mosquito-transmitted case should be conducted. The investigation should
include an epidemiologic, environmental, and laboratory component.
During this phase of the investigation, the local health department
should usually involve the state health department. This collaboration
can assist in the allocation of resources and prepare the state in the
event of further transmission across counties. The state health
department can then request the assistance of CDC, which can provide
malaria expertise and prepare for the unlikely event that the outbreak
involves several states and requires a multistate coordinated effort.

**[Epidemiologic Investigation]{.underline}**

The epidemiologic investigation has several components. The first step,
ensuring that the case definition has been met, is critical. A malaria
case is confirmed by demonstrating malaria parasites in a blood film.
Suspect cases include patients with fevers of unclear etiology.

**In-Depth Interviews**

Cases identified during an outbreak require in-depth interviews to
identify risk factors for malaria acquisition. If locally acquired
mosquito-borne transmission is a possibility, the case-patients should
be questioned about outdoor activities that might have placed them in
contact with *Anopheles* vectors, which typically bite between dusk and
dawn. An assessment of local travel, including to surrounding counties,
might help identify possible sites of acquisition.

**Case Reporting**

A primary goal of an outbreak investigation is to promptly identify all
cases of malaria in the local community, both retrospectively and
prospectively. The health department should confirm that health-care
providers or laboratories have reported all cases of malaria that have
been diagnosed. Any cases identified should be carefully reviewed to
assess their potential connection to the outbreak.

**Active Case Finding**

One characteristic of malaria is that it causes an acute febrile illness
with nonspecific symptoms. Because no distinctive clinical features are
associated with malaria, the condition of patients who seek medical care
through the health-care system might not be appropriately diagnosed,
especially if history of travel to an area where malaria is endemic has
not occurred. During an outbreak, the local health department can help
identify patients whose conditions are undiagnosed by taking several
steps.

First, all health-care sites need to be identified, including hospitals,
emergency departments, urgent-care clinics, and physicians\' offices.
Second, each of these points-of-care should collect all charts of
patients with febrile illnesses for which a clear alternative
explanation for their symptoms cannot be determined. The *International
Classification of Diseases (ICD) Ninth and Tenth Revision* codes can be
used to assist in identifying these charts, by targeting charts with
certain diagnoses (e.g., fever, nonspecified; fever, unknown origin or
viral syndrome; and fever, unspecified). A reasonable time frame to look
retrospectively for undiagnosed cases is 8 weeks before the first
recognized case. This time frame represents a biologically plausible
time interval for one to two generations of local transmission, given
the parasite and vector life cycles. Infection-control practitioners at
the selected health facility can frequently help coordinate this
process.

After the chart review, the investigation team should communicate with
health-care workers regarding each potential case to request that they
contact their respective patients and assess whether the patients are
still symptomatic. This contact should be done, if possible, through the
health-care workers to protect the integrity of the patient-physician
relationship. Patients who have been identified and who have persistent
symptoms should be reexamined, and samples should be drawn for malaria
evaluation (thick and thin blood films for diagnosis and whole blood for
further testing, if required).

**Community Sensitization**

Finally, an additional component of enhanced case detection is to alert
the medical community and the nonmedical population to the possibility
that local transmission of malaria might be occurring. This community
sensitization increases the likelihood of the identification of active
or future cases that have not yet entered into the health-care system.
Clinicians in the community need to be on alert to consider malaria in
the differential diagnosis of patients who have a fever. Visits to
select clinicians\' offices might be helpful if a substantial likelihood
exists that they might treat infected patients. The alert to health-care
providers can be combined with a request for the reporting of confirmed
cases and of cases in which persons with a nonspecific febrile illness
might seek medical care.

Alerting the nonmedical population to the possibility of being infected
with malaria will encourage patients with symptoms consistent with
malaria to seek care and educate others on how to avoid infection. The
risk for infection will differ depending on characteristics of the
outbreak (e.g., the number of persons infected and climatic changes).
This alert needs to be tailored to the community in question. Local
health departments have used reverse 911 calling (a community
notification system) to reach persons who have a telephone or have
conducted door-to-door canvassing. Settings in the community where large
numbers of persons congregate (e.g., church) should be targeted to
communicate risk messages. Various media outlets can be considered for
communicating messages regarding the possible risk for malaria,
including television, radio, and newspapers. Every effort should be made
to convey the information in the languages of the local community and to
consider the educational level of the population. CDC has designed a
malaria outbreak response tool kit that can help communicate the
messages. The tool kit is available on CDC\'s website
(<http://www.cdc.gov/malaria/references.htm>) (see table 2 of the
original guideline document.)

**[Environmental Investigation]{.underline}**

An environmental investigation includes 1) a site visit to the home of
each patient, 2) an entomologic assessment, 3) a review of meteorologic
data, and 4) an investigation of any nearby airports or seaports that
might be possible sources of infective persons or vectors.

**Site Visit**

A site visit to patients\' homes to conduct a general review of the
household, including a search for anopheline larval habitats, can help
determine the probability of whether these persons had contact with a
competent mosquito vector. This information can corroborate a history of
time spent outdoors and demonstrate the possibility for vectors being in
the home (e.g., a lack of screens and air conditioning in the home).

**Entomology**

An entomologic assessment during a locally acquired mosquito-transmitted
outbreak serves multiple potential goals. Mosquito-trapping can identify
the presence of competent vectors that would make local transmission
possible. Data on mosquito densities and breeding locations can guide
control of adult and larval mosquitoes and activities to reduce numbers
of larval habitats. Local and state health departments might already
have surveillance data on vectors in the area that is being assessed.

Trapping with the intent of identifying malaria-infected mosquitoes has
limited use. If infected mosquitoes are present, they are likely to be
in a small focus, which would be difficult to find within the large
uninfected background pool. Molecular and immunologic-based methods are
available for identification of infected mosquitoes, and efforts are
underway to address the utility of confirmation of positive mosquito
pools using PCR-based methods.

County mosquito abatement personnel can coordinate surveillance- and
vector-control efforts. If these resources are not available, the
following actions can be taken to seek needed resources: 1)
entomologists at local universities can be contacted for assistance, 2)
a private company can be contracted to conduct mosquito surveillance and
control, or 3) the state department of health can request entomologic
consultation from CDC.

**Climate and Weather**

Meteorologic data are frequently available for the county where the
outbreak has occurred. Temperature and rainfall levels throughout the
year can be used to predict the viability and abundance of the competent
vector. Analysis of weather data also can indicate whether climatic
conditions are favorable for the maturation of *Plasmodium* species
within the anopheline mosquitoes. This analysis might then be used to
guide the decision to scale-back control activities, if the temperature
is outside of a given range. For example, for *P. vivax*, the
temperature window for sporogeny to occur during the life span of the
anopheline mosquito is 60 degrees F to 91 degrees F (16 degrees C to 33
degrees C). A local health department that wants to prioritize the use
of resources might decide against the use of control measures requiring
substantial logistic capacity (e.g., spraying of insecticide or
reduction of breeding habitats) if the temperature has moved outside of
this range.

**Airport Malaria**

A remote possibility of a source for a malaria outbreak is that an
infective mosquito was transported on an aircraft or in baggage that
arrived from an area where malaria is endemic. The distance from the
airport to the patient\'s home should be ascertained and must be within
a reasonable flight path distance of the competent vector to consider
this mode of transmission as a possibility (i.e., approximately 1 mile),
although this distance can vary substantially, depending on terrain,
wind, and weather patterns. CDC has not documented any cases attributed
to airport malaria in the United States.

**[Laboratory Investigation]{.underline}**

Laboratory tools can assist and complement the epidemiologic and
environmental investigations. Techniques used in these investigations
include microscopy of blood films, PCR rRNA gene analysis, molecular
analysis of parasite DNA, and detection of antibodies produced against
parasites in the patient\'s sera.

Slide microscopy is an essential part of the case definition. If species
identification is initially uncertain, a patient should receive
treatment for *P. falciparum* while definitive speciation occurs. In
addition to blood for microscopy, whole blood (preferably pretreatment)
should be stored in case additional tests are required.

After the species has been identified by microscopy or by PCR,
additional molecular techniques (e.g., DNA sequencing) can elucidate the
parasite genotype or strain. These data can be used to track and link
the cases in an outbreak. The usefulness of this process has been
demonstrated in the latest mosquito-transmitted locally acquired malaria
outbreak in the United States, which occurred in Palm Beach County,
Florida, in 2003. All eight cases were linked by genetic analysis and
were the same strain of *P. vivax*. Molecular analysis might also assist
in determining the geographic origin of the parasite. However, the
reliability of this approach depends on the genotypic database that is
accumulated from strains obtained from specific geographic regions. This
new technique is being developed further at CDC and will continue to
provide a useful adjunct to these investigations. In the Palm Beach
County outbreak, all eight *P. vivax* parasites matched genetic patterns
consistent with a New World origin (the Americas), implicating this
region as the original source of the parasite responsible for this
outbreak.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Timely and accurate identification of malaria outbreak

-   Timely and accurate identification of malaria cases in an outbreak

-   Effective containment of malaria outbreaks

-   Effective prevention of reestablishment of an outbreak

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources\
Resources\
Tool Kits\
Wall Poster

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Centers for Disease Control and Prevention, Filler SJ, MacArthur JR,
Parise M, Wirtz R, Eliades MJ, Dasilva A, Steketee R. Locally acquired
mosquito-transmitted malaria: a guide for investigations in the United
States \[published erratum appears in MMWR Morb Mortal Wkly Rep 2006 Oct
6;55(39):1075\]. MMWR Recomm Rep 2006 Sep 8;55(RR-13):1-9. \[20
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16960552)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Sep 8

#### GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Prepared by*: Scott J. Filler, MD, Global AIDS Program, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC,
Atlanta, Georgia; John R. MacArthur, MD, Division of Parasitic Diseases,
National Center for Zoonotic, Vector-Borne, and Enteric Diseases
(proposed), CDC, Atlanta, Georgia; Monica Parise, MD, Division of
Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and
Enteric Diseases (proposed), CDC, Atlanta, Georgia; Robert Wirtz, PhD,
Division of Parasitic Diseases, National Center for Zoonotic,
Vector-Borne, and Enteric Diseases (proposed), CDC, Atlanta, Georgia; M.
James Eliades, MD, Division of Parasitic Diseases, National Center for
Zoonotic, Vector-Borne, and Enteric Diseases (proposed), CDC, Atlanta,
Georgia; Alexandre Dasilva, PhD, Division of Parasitic Diseases,
National Center for Zoonotic, Vector-Borne, and Enteric Diseases
(proposed), CDC, Atlanta, Georgia; Richard Steketee, MD, PATH, Seattle,
Washington

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and
Prevention (CDC) Web site:

-   [HTML Format](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5513a1.htm)

-   [Portable Document Format
    (PDF)](http://www.cdc.gov/mmwr/PDF/rr/rr5513.pdf)

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Outbreaks of locally transmitted malaria health information tookit,
    including fact sheets, brochures, contact letters, postcards,
    posters, and media press releases.

Electronic copies: Available from the [Centers for Disease Control and
Prevention (CDC) Web
site](http://www.cdc.gov/malaria/outbreak_toolkit.htm).

#### PATIENT RESOURCES

The following is available:

-   Outbreaks of locally transmitted malaria health information tookit,
    including fact sheets, brochures, contact letters, postcards,
    posters, and media press releases.

Electronic copies: Available from the [Centers for Disease Control and
Prevention (CDC) Web
site](http://www.cdc.gov/malaria/outbreak_toolkit.htm).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on November 17, 2006.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008