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## Complete Summary

#### GUIDELINE TITLE

Updated interim CDC guidance for use of smallpox vaccine, cidofovir, and
vaccinia immune globulin (VIG) for prevention and treatment in the
setting of an outbreak of monkeypox infections.

#### BIBLIOGRAPHIC SOURCE(S)

Centers for Disease Control and Prevention. Updated interim CDC guidance
for use of smallpox vaccine, cidofovir, and vaccinia immune globulin
(VIG) for prevention and treatment in the setting of an outbreak of
monkeypox infections. Atlanta (GA): Centers for Disease Control and
Prevention; 2003 Jun 25. 7 p. \[14 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Centers for Disease Control
and Prevention. Interim guidance for use of smallpox vaccine, cidofovir,
and vaccinia immune globulin (VIG) for prevention and treatment in the
setting of an outbreak monkeypox infections. Atlanta (GA): Centers for
Disease Control and Prevention; 2003 Jun 12. 6 p.

### COMPLETE SUMMARY CONTENT

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

### SCOPE

#### DISEASE/CONDITION(S)

Monkeypox infection

#### GUIDELINE CATEGORY

Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

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

#### INTENDED USERS

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

#### GUIDELINE OBJECTIVE(S)

To provide guidance on the use of smallpox vaccine, cidofovir and
vaccinia immune globulin (VIG) for purposes of monkeypox outbreak
control

#### TARGET POPULATION

Adults and children diagnosed with or exposed to monkeypox including:

-   Investigators of suspected human and animal monkeypox

-   Health care workers

    -   caring for confirmed monkeypox cases or recently involved in
        such care

    -   selected to care for suspected monkeypox patients

-   Clinical laboratory workers

-   Close contacts, household contacts and others who have had close or
    intimate contact with confirmed human cases, and who are within 4
    days of initial direct exposure to a monkeypox case

-   Persons who have been exposed to a recently acquired prairie dog or
    other small mammals from implicated distributors

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Smallpox vaccine (available under an investigational new drug
    \[IND\] protocol sponsored by CDC)

2.  Vaccinia immune globulin (considered but not recommended)

3.  Cidofovir (considered only for life-threatening monkeypox
    infections)

#### MAJOR OUTCOMES CONSIDERED

-   Efficacy of smallpox vaccination for prevention of monkeypox

-   Risk of death from smallpox vaccine

### 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

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note**: Because of the potential seriousness of this disease, the
Centers for Disease Control and Prevention (CDC) has developed interim
guidance to balance the risks of smallpox vaccination against the risks
posed by exposure to monkeypox infection. This interim guidance will be
re-evaluated as more information becomes available.

Smallpox vaccine for controlling outbreaks of monkeypox would be
available under an investigational new drug (IND) protocol sponsored by
CDC.

**General Recommendations**

It is important that vaccinators, as currently occurs in the pre-event
smallpox vaccination program, screen potential vaccinees for precautions
and contraindications to smallpox vaccination and evaluate vaccination
sites for a successful vaccination (i.e., a major reaction at the site
6-8 days after vaccination). Persons without a successful vaccine take
should be revaccinated within 2 weeks of the most recent exposure to
monkeypox. State and local health departments should provide information
on how vaccinees should seek consultation on evaluation of vaccination
sites for major reactions or for potential complications of vaccination.

Rash illnesses suspected to be monkeypox should be confirmed by
laboratory evaluation, which, in addition to determining the presence of
monkeypox, should have the capability to detect varicella, vaccinia and
other relevant viruses. Laboratory confirmation of monkeypox cases is
particularly important before recommending vaccination to persons with
close or intimate contact with a monkeypox case and considered to have
contraindications to smallpox vaccination in the pre-event smallpox
vaccination (e.g., pregnant women, persons with eczema, and children
aged \<1 year). Intimate contact refers to contact resulting in exposure
to body fluids or lesions of ill persons or ill animals. The period of
communicability (i.e., exposure period for contacts) for humans may be
from 1 day before onset of rash up to 21 days after rash or illness
onset or when all rash lesions have scabbed over. The period of
communicability (i.e., exposure period for contacts) for animals may be
from 1 day before onset of illness up to 21 days after rash or illness
onset or when the ill animal is removed from possible exposure with the
contact, or when the animal´s clinical illness ends and all rash lesions
have scabbed over. As general guidance, for purposes of smallpox
exposure (for human-to-human transmission), close contact has been
defined as [\>]{.underline}3 hours of direct (face-to-face) exposure
within 6 feet; this is reasonable guidance for exposure to monkeypox
from humans as well. In animal care settings, close contact has been
defined as direct exposure within 6 feet of an animal suspected to have
monkeypox with respiratory symptoms such as nasal discharge, cough, or
conjunctivitis in a setting where the animal has been manipulated (e.g.,
an exam room). However, judgment must be applied to determine the
significance of contact in individual exposure situations.

**Who Should be Vaccinated?**

-   **Investigators of suspected human or animal monkeypox**

> Ideally investigators of suspected monkeypox cases should have
> received smallpox vaccination within the past 1-3 years. When
> possible, priority should be given to using investigators,
> veterinarians, and animal control personnel who previously were
> vaccinated and who had a confirmed take. Ideally the vaccination site
> should have crusted over before deployment. However, if this is not
> feasible these individuals may be vaccinated immediately before
> deploying for the field investigation. Unvaccinated investigators
> currently involved in field investigations or who have been recently
> involved in such work should be vaccinated as soon as possible,
> preferably within 4 days from initial direct exposure. Any
> investigator with an active vaccination site that is not healed should
> follow the precautions advised for health care workers (HCWs) with
> regard to the vaccination site care to avoid potential contamination
> of field samples or of transmission of vaccinia to others.
>
> Field investigators of suspected cases of monkeypox should observe
> recommended standard, contact, and air-borne infection control
> precautions even if vaccinated. These include the use of recommended
> personal protection equipment (currently N95 or comparable respirator)
> when appropriate. [Interim guidance for infection control and exposure
> management in the health-care and community setting for patients with
> possible monkeypox virus
> infection](http://www.cdc.gov/ncidod/monkeypox/infectioncontrol.htm).

-   **Health Care Workers (HCWs)**

    -   *Previously or currently exposed HCWs*: HCWs currently caring
        for confirmed monkeypox cases or who have been recently involved
        in such care should be vaccinated. Vaccination should occur as
        soon as possible after confirmed exposure. Vaccination is
        recommended for persons who are within 4 days of initial direct
        (intimate or close) exposure and should be considered only for
        persons who are within 2 weeks of most recent exposure.
        Vaccination sites should be managed as recommended for HCWs in
        the pre-event smallpox vaccination program. Persons without a
        vaccine take by day 7 should only be revaccinated if within 2
        weeks of most recent exposure.

    -   *HCWs who may be asked to care for monkeypox patients in the
        future*: Ideally, HCWs selected to care for suspected monkeypox
        cases should not have any of the contraindications to smallpox
        vaccination in the pre-event smallpox vaccination setting. When
        possible, priority should be given to having HCWs who were
        previously vaccinated, with confirmed takes, care for patients
        with suspected monkeypox. When such workers are unavailable,
        HCWs may be vaccinated immediately prior to beginning their
        clinical care duties. Vaccination sites should be managed as
        recommended for HCWs in the pre-event vaccination program.

> HCWs who care for suspected cases of monkeypox should continue to
> observe recommended standard, contact, and air-borne infection control
> precautions including use of personal protective equipment (currently
> N95 or comparable respirator) when appropriate, even if vaccinated.

-   *Clinical laboratory workers*: [Interim guidance on vaccination and
    appropriate handling of routine clinical laboratory specimens from
    animals or persons suspected to be infected with
    monkeypox](http://www.cdc.gov/ncidod/monkeypox/lab.htm).

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```
-   **Contacts**

> Close contacts, defined as household contacts as well as others who
> have had close or intimate contact with confirmed human cases, and who
> are within 4 days of initial direct exposure to a monkeypox case
> should be vaccinated. Vaccination should be considered for persons who
> are within 2 weeks of most recent exposure. As general guidance, for
> purposes of smallpox exposure, close contact has been defined as
> [\>]{.underline} 3 hours of direct exposure within 6 feet and this is
> reasonable guidance for monkeypox exposure as well. Intimate contact
> refers to contact resulting in exposure to body fluids or lesions of
> affected persons. However, judgment must be applied to determine the
> significance of contact in individual exposure situations. State and
> local health departments should be consulted regarding decisions about
> vaccination of contacts, and in particular be consulted for contacts
> who may not meet the strict definitions of close or intimate contact
> above, especially in child care, school, or health care settings.

Vaccination sites should be managed as recommended for HCWs in the
pre-event smallpox vaccination program. Persons who care for recently
vaccinated children should be particularly vigilant to observe
recommended standard and contact infection control precautions with the
vaccination site. Persons without a vaccine take by day 7 should only be
revaccinated if within 2 weeks of most recent exposure.

-   **Persons who have been exposed to a recently acquired prairie dog
    or other small mammals from implicated distributors**

> Smallpox vaccination should be recommended for persons who have,
> within the past 4 days, had direct physical (intimate) contact with
> ill prairie dogs or other ill small mammals meeting the probable or
> confirmed case definitions for monkeypox from implicated distributors
> acquired since April 15 within the affected areas. The [interim case
> definition for animal cases of
> monkeypox](http://www.cdc.gov/ncidod/monkeypox/animalcasedefinition.htm).
> Vaccination should be considered for persons who are within 2 weeks of
> most recent exposure. In addition, vaccination can be considered for
> persons who have close contact with an ill animal that meets the
> probable or confirmed animal case definition. Close contact is defined
> as direct exposure within 6 feet of a probable or confirmed monkeypox
> case in an animal with respiratory symptoms such as nasal discharge,
> cough, or conjunctivitis in a setting where the animal has been
> manipulated (e.g., an exam room). Smallpox vaccination is not
> recommended for persons exposed to a healthy animal.

These recommendations may change should evidence show that other
symptomatically ill small mammals pose significant risk for human
monkeypox.

Vaccination sites should be managed as recommended for HCWs in the
pre-event smallpox vaccination program. Persons who care for recently
vaccinated children should be particularly vigilant to observe
recommended standard and contact infection control precautions with the
vaccination site. Persons without a vaccine take by day 7 should only be
revaccinated if within 2 weeks of most recent exposure.

Veterinary health care workers should observe [recommended infection
control
practices](http://www.cdc.gov/ncidod/monkeypox/animalguidance.htm)
including use of personal protective equipment when appropriate, even if
vaccinated. It is anticipated that fit-tested N95 respirators will not
be available in most veterinary facilities; when currently N95 or
comparable respirators are unavailable, surgical masks should be worn to
protect against transmission through contact or large droplets. Exposed
veterinarians and staff without N95 (or comparable) respirator
protection who have direct or close contact to animals with monkeypox
should be vaccinated according to the guidelines. [Interim guidance for
infection control and exposure management in the health-care and
community setting for patients with possible monkeypox virus
infection](http://www.cdc.gov/ncidod/monkeypox/infectioncontrol.htm).

[Interim guidance on appropriate handling of routine clinical laboratory
specimens from animals suspected or confirmed to be infected with
monkeypox](http://www.cdc.gov/ncidod/monkeypox/labbiosafetyguide.htm).

**Contraindications to Smallpox Vaccination (Refer to the
\"Contraindications\" field)**

**Vaccinia Immune Globulin (VIG)**

No data are available on the effectiveness of VIG in treatment of
monkeypox complications. VIG has no proven benefit in the treatment of
smallpox complications. It is unknown whether a person with severe
monkeypox infection will benefit from treatment with VIG, however, its
use may be considered in such instances. VIG can be considered for
prophylactic use in an exposed person with severe immunodeficiency in
T-cell function for whom smallpox vaccination following exposure to
monkeypox is contraindicated.

**Cidofovir**

No data are available on the effectiveness of cidofovir in treatment of
human monkeypox cases. However, cidofovir has proven anti-monkeypox
viral activity in *in vitro* and in animal studies. It is unknown
whether a person with severe monkeypox infection will benefit from
treatment with cidofovir, however, its use may be considered in such
instances. Cidofovir has significant toxicity and should only be
considered for treatment of severe monkeypox infections, not for
prophylactic use.

Clinical consultation on the use of VIG and cidofovir is available from
staff at each state health department in the affected states. In
addition, clinical consultation is available from staff at the CDC.

**Vaccination of Veterinarians, Veterinary and Animal Control Staff**

Similar to health care workers, at this time pre-exposure smallpox
vaccination is not recommended for unexposed veterinarians, veterinary
staff, and animal control officers in the affected areas, but routine
use of appropriate standard, contact and air-borne infection control
measures should be stressed.

Persons who may be involved in field investigations involving
potentially infected animals should be vaccinated in advance. This
recommendation will be re-evaluated as more information becomes
available.

Laboratory workers (e.g., veterinary pathologists) at designated
reference laboratories who handle specimens from ill prairie dogs or
other ill small mammals meeting the probable or confirmed case
definitions for monkeypox from implicated distributors acquired since
April 15 within the affected states should be vaccinated as recommended
for field investigators or health care workers anticipated to have
future contact with suspected monkeypox cases.

**Reporting of Adverse Events Associated with Smallpox Vaccination**

Serious adverse events after smallpox vaccination should be reported to
the Vaccine Adverse Event Reporting System (VAERS). Refer to the
original guideline document for details.

#### CLINICAL ALGORITHM(S)

Not applicable

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated. In most
instances, only limited data are available on which to directly base
recommendations and thus the guidance is primarily based on expert
opinion. This interim Centers for Disease Control and Prevention (CDC)
guidance was developed using the best available information about the
benefits and risks of smallpox vaccination, vaccinia immune globulin and
cidofovir for prevention and/or management of smallpox, monkeypox and
complications of vaccinia infection.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Limited information is available on efficacy of smallpox vaccination for
prevention of monkeypox. The data suggest that pre-exposure smallpox
vaccination is highly effective ([\>]{.underline}85%) in protecting
persons exposed to monkeypox from disease. No information is available
on the efficacy of post-exposure vaccination. Data which suggest
smallpox vaccination following exposure to smallpox is effective in
preventing or ameliorating disease, suggest that post-exposure smallpox
vaccination should have similar impact against monkeypox. Data from
investigations in Africa in the 1980s suggested that in household
settings, secondary transmission occurred to about 8% to 15% of
contacts. Among infected human cases, reported mortality rates have
ranged from 1% to 10%, the risk of death from smallpox vaccine is
estimated to be 1-2 per million vaccinees.

#### POTENTIAL HARMS

-   Complications of smallpox vaccination

-   Cidofovir has significant toxicity and should only be considered for
    treatment of severe monkeypox infections, not for prophylactic use.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

The nature of exposure should be assessed carefully for health care
workers (HCWs), household, close or intimate contacts who have been
exposed within the past 2 weeks to a probable or confirmed animal case
or confirmed human case of monkeypox, but who have contraindications to
smallpox vaccine receipt in the pre-event smallpox setting. If there are
difficulties in obtaining rapid laboratory confirmation, the state
health department should be urgently consulted. The risk of monkeypox
disease for persons with a close or intimate exposure to confirmed
monkeypox cases is believed to be greater than the risk of adverse
events resulting from vaccinia exposure for most persons for whom
smallpox vaccination would be otherwise contraindicated in the pre-event
smallpox vaccination setting. In the post-exposure setting, the benefit
of vaccination outweighs the risk of vaccination. In this setting, most
contraindications are considered precautions to vaccination. In persons
with close or intimate exposure within the past 2 weeks to a confirmed
human case or probable or confirmed animal case of monkeypox, neither
age, pregnancy, nor a history of eczema are contraindications to receipt
of smallpox vaccination. These conditions are precautions and not
contraindications. Active eczematous disease is more concerning, but in
instances when the potential vaccinee has had true close or intimate
exposure, the risk of contracting monkeypox would likely still be
greater than the risk of complications of smallpox vaccination.
Appropriate site care should be used to prevent transmission of smallpox
vaccine (vaccinia virus) from vaccinated persons to other non-vaccinated
household members.

Smallpox vaccination is still contraindicated for:

1.  Persons who have severe immunodeficiency in T-cell function, defined
    as:

    -   Human immunodeficiency virus (HIV)-infected adults with CD4
        lymphocyte count less than 200 (or age appropriate equivalent
        counts for HIV infected children);

    -   Solid organ, bone marrow transplant recipients or others
        currently receiving high dose immunosuppressive therapy (i.e., 2
        mg/kg body weight or a total of 20 mg/day of prednisone or
        equivalent for persons whose weight is \> 10 kg, when
        administered for \> 2 weeks); and

    -   Persons with lymphosarcoma, hematological malignancies, or
        primary T-cell congenital immunodeficiencies.

2.  Persons with life-threatening allergies to latex or to smallpox
    vaccine or any of its components (polymyxin B, streptomycin,
    chlortetracycline, neomycin).

These persons have a risk of severe complications from smallpox
vaccination that may approach or exceed the risk of disease from
monkeypox exposure. Consultation with state and local health departments
and the Centers for Disease Control and Prevention (CDC) should be
sought regarding judgments about vaccination of such persons in the
post-exposure setting.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

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

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Centers for Disease Control and Prevention. Updated interim CDC guidance
for use of smallpox vaccine, cidofovir, and vaccinia immune globulin
(VIG) for prevention and treatment in the setting of an outbreak of
monkeypox infections. Atlanta (GA): Centers for Disease Control and
Prevention; 2003 Jun 25. 7 p. \[14 references\]

#### ADAPTATION

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

#### DATE RELEASED

2003 Jun 12 (revised 2003 Jun 25)

#### 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

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Centers for Disease Control
and Prevention. Interim guidance for use of smallpox vaccine, cidofovir,
and vaccinia immune globulin (VIG) for prevention and treatment in the
setting of an outbreak monkeypox infections. Atlanta (GA): Centers for
Disease Control and Prevention; 2003 Jun 12. 6 p.

#### GUIDELINE AVAILABILITY

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

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 clinical resources are available:

-   [Updated interim infection control and exposure management guidance
    in the health-care & community setting for patients with possible
    monkeypox virus
    infection](http://www.cdc.gov/ncidod/monkeypox/infectioncontrol.htm)
    (2003 Jun 24).

-   [Updated interim case definition for human case of
    monkeypox](http://www.cdc.gov/ncidod/monkeypox/casedefinition.htm)
    (2003 Jul 2).

-   [Interim biosafety guidelines for laboratory personnel handling
    human and animal specimens for monkeypox
    testing](http://www.cdc.gov/ncidod/monkeypox/labbiosafetyguide.htm)
    (June 23, 2003).

-   [Laboratory testing of human and animal
    specimens](http://www.cdc.gov/ncidod/monkeypox/lab.htm) (2003 Jun
    25).

-   [Monkeypox infections in animals: updated interim guidance for
    veterinarians](http://www.cdc.gov/ncidod/monkeypox/animalguidance.htm)
    (2003 Jun 27).

Other group-specific information about monkeypox is also available at
the [Centers for Disease Control and Prevention (CDC) Web
site](http://www.cdc.gov/ncidod/monkeypox/index.htm).

#### PATIENT RESOURCES

The following are available:

-   Fact sheets: basic information about monkeypox. Atlanta (GA):
    Centers for Disease Control and Prevention (CDC); 2003 Jun 12. 2 p.

-   Questions and answers about monkeypox. Atlanta (GA): Centers for
    Disease Control and Prevention (CDC); 2003 Jul 7. 4 p.

-   What pet owners should know about monkeypox. Atlanta (GA): Centers
    for Disease Control and Prevention (CDC); 2003 Jun 27. 4 p.

-   What pet shop owners should know about monkeypox. Atlanta (GA):
    Centers for Disease Control and Prevention (CDC); 2003 Jun 27. 4 p.

-   What you should know about monkeypox. Atlanta (GA): Centers for
    Disease Control and Prevention (CDC); 2003 Jun 12. 2 p.

-   Smallpox vaccine and monkeypox. Atlanta (GA): Centers for Disease
    Control and Prevention (CDC); 2003 Jul 7. 2 p.

Electronic copies of these and other related materials are available
from the [CDC Web site](http://www.cdc.gov/ncidod/monkeypox/index.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 summary was completed by ECRI on June 23, 2003. It was updated by
ECRI on July 8, 2003. The information was not verified by the guideline
developer.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008