Appendix A   Task Force Ratings 
 
The tables of ratings on the following pages were developed for the U.S.  
Preventive Services Task Force using the methodology adapted from the Canadian  
Task Force on the Periodic Health Examinationa and described in Chapter ii. For  
this edition of the Guide, the Task Force developed ratings for all of the  
topics examined. 
 
The Task Force graded the strength of recommendations for or against preventive  
interventions as follows. 
 
Strength of Recommendations 
 
A: There is good evidence to support the recommendation that the condition be  
specifically considered in a periodic health examination. 
 
B: There is fair evidence to support the recommendation that the condition be  
specifically considered in a periodic health examination. 
 
C: There is insufficient evidence to recommend for or against the inclusion of  
the condition in a periodic health examination, but recommendations may be made  
on other grounds. 
 
D: There is fair evidence to support the recommendation that the condition be  
excluded from consideration in a periodic health examination. 
 
E: There is good evidence to support the recommendation that the condition be  
excluded from consideration in a periodic health examination. 
 
Determination of the quality of evidence (i.e., "good," "fair," "insufficient")  
in the strength of recommendations was based on a systematic consideration of  
three criteria: the burden of suffering from the target condition, the  
characteristics of the intervention, and the effectiveness of the intervention  
as demonstrated in published clinical research. Effectiveness of the  
intervention received special emphasis. In reviewing clinical studies, the Task  
Force used strict criteria for selecting admissible evidence and placed emphasis 
on the quality of study designs. In grading the quality of evidence, the Task  
Force gave greater weight to those study designs that, for methodologic reasons, 
are less subject to bias and inferential error. The following rating system was  
used. 
 
Quality of Evidence 
 
I: Evidence obtained from at least one properly randomized controlled trial. 
 
II-1:   Evidence obtained from well-designed controlled trials without  
randomization. 
 
II-2:   Evidence obtained from well-designed cohort or case-control analytic  
studies, preferably from more than one center or research group. 
 
II-3:   Evidence obtained from multiple time series with or without the  
intervention. Dramatic results in uncontrolled experiments (such as the results  
of the introduction of penicillin treatment in the 1940s) could also be regarded 
as this type of evidence. 
 
III:    Opinions of respected authorities, based on clinical experience;  
descriptive studies and case reports; or reports of expert committees. 
 
Well-designed and well-conducted meta-analyses were also considered, and were  
graded according to the quality of the studies on which the analyses were based  
(e.g., Grade I if the meta-analysis pooled properly randomized controlled  
trials). 
 
An exact correlation does not exist between the strength of the recommendation  
and the level of evidence, i.e., Level I evidence did not necessarily lead to an 
A grade, nor did an A grade require Level I evidence. For example, there may  
have been evidence of good quality that did not prove that an intervention is  
effective (e.g., mammography in women under age 50, which received a C  
recommendation). On the other hand, an A recommendation was given to screening  
for cervical cancer with Papanicolaou testing, based on burden of suffering and  
Level II evidence supporting the effectiveness of the intervention. For many  
preventive services, there is insufficient evidence to determine whether or not  
routine intervention will improve clinical outcomes (C recommendation). A  
variety of different circumstances can result in a OCO recommendation: available 
studies are not adequate to determine effectiveness (e.g., insufficient  
statistical power, unrepresentative populations, lack of clinically important  
endpoints, or other important design flaws); high-quality studies have produced  
conflicting results; evidence of significant benefits is offset by evidence of  
important harms from intervention; or studies of effectiveness have not been  
conducted. As a result, lack of evidence of effectiveness does not constitute  
evidence of ineffectiveness. Chapter ii provides further information about the  
methodology used to develop the body of this report.

Table 1. Screening for Asymptomatic Coronary Artery Disease 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine resting,                II-2                            C 
ambulatory, or exercise     
electrocardiography in  
middle-aged or older persons 
 
Routine resting electro-        III                             D 
cardiography in healthy  
children, adolescents, or young 
adults, including those  
undergoing pre-participation  
sports physicals 
 
 
Table 2. Screening for High Blood Cholesterol and Other Lipid Abnormalities 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine measurement of  
 total serum or blood  
 cholesterol 
  Men aged 35-65 yr             I, II-2                         B 
  Women aged 45-65 yr           II-2                            B 
  Persons aged > 65 yr          II-2                            C 
  Children, adolescents,        II-2                            C 
   young adults                   
Routine measurement of HDL-C    II-2, III                       C 
Routine measurement of          II-2                            C 
 triglycerides 
 
 
Table 3. Screening for Hypertension 
 
Intervention            Level of Evidence       Strength of Recommendation 
---------------------------------------------------------------------------      
Periodic blood pressure         I                               A  
 measurement in persons    
 aged 21 yrs or older 
Measurement of blood            II-2, II-3, III                 B 
 pressure in children and   
 adolescents during office 
 visits 
 
 
Table 4. Screening for Asymptomatic Carotid Artery Stenosis 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine carotid                 I, II-2                         C 
 ultrasound or auscultation 
 for carotid bruits in 
 older persons 
 
 
Table 5. Screening for Peripheral Arterial Disease 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine history-taking          III                             D 
 for classic claudication, 
 palpation of peripheral  
 pulses, ultrasound, or  
 other noninvasive tests 
 in older persons 
 
 
Table 6. Screening for Abdominal Aortic Aneurysm 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine abdominal               II-2                            C 
 palpation 
Routine abdominal               II-2                            C 
 ultrasound 
 
 
Table 7. Screening for Breast Cancer 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine mammogram every 
 1-2 yr with or without 
 annual clinical breast 
 exam 
   Women aged 40-49 yr          I                               C 
              50-69 yr          I, II-2                         A 
              70-74 yr          I, II-3                         C 
              75 yr and older   III                             C 
Annual clinical breast 
 exam without periodic 
 mammograms 
   Women aged 40-49 yr          III                             C 
              50-59 yr          I                               C 
              60 yr and older   III                             C 
Routine breast 
 self-exam                      I, II-2, III                    C 
 
 
 
Table 8. Screening for Colorectal Cancer 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Annual fecal occult             I, II-1, II-2                   B 
 blood testing of persons  
 aged 50 yr and older 
Routine sigmoidoscopy           II-2, II-3                      B 
 in persons aged 
 50 yr and older 
Routine digital rectal exam     III                             C 
Routine barium enema            III                             C 
Routine colonoscopy             III                             C 
 
 
Table 9. Screening for Cervical Cancer 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Regular Pap testing in          II-2, II-3                      A 
 women who are or have  
 been sexually active and  
 who have a cervix 
Discontinuation of              III                             C 
 regular Pap testing in  
 women aged >65 yr 
Routine cervicography or        III                             C 
 colposcopy  
Routine testing for HPV         III                             C 
 infection 
 
 
Table 10. Screening for Prostate Cancer 
 
Intervention            Level of Evidence      Strength of Recommendation 
------------------------------------------------------------------------- 
Routine digital rectal          II-2                            D 
 exam 
Routine prostate-specific       I, II-2, III                    D 
 antigen or other serum 
 tumor markers 
Routine transrectal ultrasound  II-2, III                       D 
 
 
Table 11. Screening for Lung Cancer 
 
Intervention            Level of Evidence      Strength of Recommendation 
------------------------------------------------------------------------- 
Routine chest x-ray             I, II-1, II-2                   D 
 or sputum cytology 
 
 
Table 12. Screening for Skin Cancer-Including Counseling to Prevent Skin Cancer 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
                                        Screening 
Total body skin exam by         II-3, III                       C 
 primary care clinicians 
Periodic skin self-exam         II-3, III                       C 
 
                                        Primary Prevention 
Sun avoidance or use of         II-2                            B 
 protective clothing by        
 high-risk* persons 
Routine use of sunscreens       I, II-2                         C 
 Clinician counseling to        III                             C 
 increase the use of   
 sun protection measures 
 
 
Table 13. Screening for Testicular Cancer 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine self-exam or            III                             C 
 physician exam of the 
 testes in men 
 
 
 
Table 14. Screening for Ovarian Cancer 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine pelvic exam,  
 ultrasound, or  
 serum tumor markers   
   General female population    II-3, III                       D 
   High-risk* women             III                             C 
 
 
Table 15. Screening for Pancreatic Cancer 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine abdominal               III                             D 
 palpation, ultrasound,  
 or serum tumor markers 
 
 
Table 16. Screening for Oral Cancer 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine oral exam               III                             C 
 by primary care clinicians 
 
 
Table 17. Screening for Bladder Cancer 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine urine dipstick          II-2, III                       D 
 or microscopy 
Routine urine cytology          III                             D 
      
 
Table 18. Screening for Thyroid Cancer 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine neck palpation 
 or ultrasound 
  General population            II-2, III                       D 
  High-risk* adults             III                             C 
   or children       
 
 
Table 19. Screening for Diabetes Mellitus 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Non-insulin-dependent:             
 Routine measurement of         II-2                            C 
  plasma glucose, glyco- 
  sylated hemoglobin,  
  or urine glucose  
 
Gestational:              
 Routine oral 1-hr              I, II-2                         C 
  glucose challenge test,          
  glycosolated hemoglobin,  
  fasting or random plasma  
  glucose, or urine glucose 
 
Insulin-dependent:            
 Routine measurement of         III                             D 
  serum auto-antibodies in the  
  general population 
 
 
 
Table 20. Screening for Thyroid Disease 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine thyroid function  
 tests 
  General population            III                             D 
  High-risk* persons            I, II-3                         C 
    
 
Table 21. Screening for Obesity 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Periodic height and             I, II-2, II-3                   B 
 weight measurements       
Routine determination           II-2                            C 
 of the waist/hip ratio 
 
 
Table 22. Screening for Iron Deficiency Anemia-Including Iron Prophylaxis 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
                                        Screening 
Routine hemoglobin/ 
 hematocrit 
  Pregnant women at             II-1, II-2                      B 
   first prenatal visit  
  High-risk* infants            I                               B 
  High-risk* children           I                               C 
  General population            I, II-1, II-2                   C 
Repeat hemoglobin/              III                             C 
 hematocrit in pregnant  
 women or high-risk* infants   
 not anemic at initial testing 
 
                                Primary Prevention 
Breastfeeding and use of iron-  I, II-1, II-2, II-3             B 
 enriched formula or food for   
 all infants and toddlers 
Routine use of iron supplements 
 Healthy pregnant women         I, II-1, II-2                   C 
 Healthy infants                I, III                          C 
 
 
Table 23. Screening for Elevated Lead Levels in Childhood and Pregnancy 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
                                        Screening 
Routine blood lead 
 measurement         
  High-risk* children           II-1, II-2, II-3                B 
  Pregnant women                III                             C 
   
                                Primary Prevention 
Routinely counseling            II-2, III                       C 
 families to control lead  
 dust by repeated household  
 cleaning, or to optimize  
 caloric, iron, and calcium  
 intake specifically to  
 reduce lead absorption 
 
 
Table 24. Screening for Hepatitis B Virus Infection 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine measurement  
 of HBsAg 
  Pregnant women                I, II-1, II-2, II-3             A 
  High-risk* persons            III                             C 
  (to assess eligibility 
   for vaccination) 
  General population            III                             D 
 
 
Table 25. Screening for Tuberculous Infection-Including BCG Immunization 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Tuberculin skin testing         I                               A 
 of high-risk* persons 
BCG vaccination of              I, II-2                         B 
 selected high-risk*  
 infants and children 
 
 
 
Table 26. Screening for Syphilis 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine serologic testing 
 High-risk* persons             II-3                            A 
 Pregnant women                 II-3                            A 
 
 
Table 27. Screening for Gonorrhea-Including Ocular Prophylaxis in Newborns 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
                                        Screening 
Routine gonorrhea culture  
 or nonculture screening  
 test 
  High-risk* women              II-2, III                       B 
  High-risk* pregnant women     II-2                            B 
  Other pregnant women          III                             C 
  High-risk* men                II-3, III                       C 
  General population            III     D 
 
        Primary Prevention of Gonococcal Ophthalmia Neonatorum 
Routine ophthalmic anti-        II-3, III                       A 
 biotic in newborns     
 
 
Table 28. Screening for Human Immunodeficiency Virus Infection 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Enzyme immunoassay,  
 with confirmatory test  
 for positive results 
  High-risk* adolescents        I, II-2                         A 
   and adults 
  High-risk* pregnant women     I, II-2                         A 
  High-risk* infants            II-2                            B 
  Low-risk pregnant women,      III                             C 
   adolescents,and adults 
 
 
Table 29. Screening for Chlamydial InfectionIncluding Ocular Prophylaxis in     
 Newborns 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
                                        Screening 
Routine culture or non-  
 culture screening test  
  Sexually active female        I, II-2, III                    B  
   adolescents and other  
   high-risk* women             
  High-risk* pregnant women     II-2                            B 
  Other pregnant women          III                             C 
  High-risk* men                II-3, III                       C 
  General population            III                             D 
 
                Primary Prevention of Chlamydial Ophthalmia Neonatorum 
Routine ophthalmic              I, II-2, III                    C 
 antibiotic in newborns 
 
 
Table 30. Screening for Genital Herpes Simplex 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
                                        Screening 
Routine viral culture,  
 serology, or other tests 
  General population            II-3, III                       D 
  Pregnant women                II-2, II-3, III                 D 
  Examination of pregnant       II-2, III                       C  
   women in labor for  
   signs of active genital  
   HSV lesions 
 
                    Primary Prevention of Neonatal Herpes Infection 
Routine use of systemic         III                             C 
 acyclovir in pregnant  
 women with recurrent herpes 
Counseling uninfected women     III                             C 
 with infected partners to  
 use condoms or abstain from  
 intercourse during pregnancy 
 
 
Table 31. Screening for Asymptomatic Bacteriuria 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine urine culture in        I                               A 
 pregnant women at 12-16  
 weeks' gestation 
Routine urine dipstick  
 for leukocyte esterase/ 
 nitrites 
  Pregnant women                II-2                            D 
  Diabetic women                III                             C 
  Noninstitutionalized          I, II-1, II-2                   C 
   elderly women 
  Institutionalized elders      I                               E 
  School-aged girls             I                               E 
  Other persons                 I, II-2, III                    D 
Routine urine microscopy        II-2                            D 
 
 
Table 32. Screening for Rubella-Including Immunization of Adolescents and  
 Adults 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine rubella serology  
 or vaccination history 
  Women of childbearing age     II-2, II-3, III                 B 
   (including pregnant women) 
  Young men in high-risk*       II-3, III                       C 
   settings 
  Other men and postmenopausal  III                             D 
   women 
Routine rubella vaccination 
 without screening 
  Children                      I, II-1, II-2, II-3             A 
  Nonpregnant women of          II-2, III                       B 
   childbearing age 
  Young men in high-risk*       II-2, III                       C 
   settings 
  Other men and postmenopausal  III     D 
   women 
 
 
Table 33. Screening for Visual Impairment 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine testing for             II-1, II-2                      B 
 amblyopia and strabismus  
 in preschool children 
Routine Snellen acuity          II-3                            B 
 testing in elderly persons      
Routine ophthalmoscopy by       III                             C 
 primary care clinicians in  
 elderly persons 
Routine vision screening in     III                             C 
 other children, adolescents, 
 and adults 
 
 
Table 34. Screening for Glaucoma 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine tonometry               I, II-2, III                    C 
Routine ophthalmoscopy          III                             C 
 by primary care clinicians 
 
 
Table 35. Screening for Hearing Impairment 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Periodically questioning        I, III                          B 
 older adults about their  
 hearing 
Routine audiometric testing     I, III                          C 
 in older adults 
Routine hearing testing in      III                             C 
 adolescents and working-age 
 adults<1> 
Routine evoked otoacoustic      II-2, III                       C 
 emission testing or auditory   
 brainstem response in newborns 
Routine hearing testing in      II-2                            D 
 children aged >3 yr 
 
<1>Screening of workers for noise-induced hearing loss should be performed  
in the context of existing worksite programs and occupational medicine  
guidelines. 
 
 
Table 36. Screening Ultrasonography in Pregnancy 
 
Intervention            Level of Evidence       Strength of Recommendation 
-------------------------------------------------------------------------- 
Routine midtrimester            I                               C 
 ultrasound in pregnant women 
Routine third-trimester         I                               D 
 ultrasound in pregnant women 
 
 
Table 37. Screening for Preeclampsia 
 
Intervention            Level of Evidence      Strength of Recommendation 
------------------------------------------------------------------------- 
Periodic blood pressure         II-3, III                       B 
 measurement during pregnancy, 
 as part of routineprenatal care 
 
 
Table 38. Screening for D (Rh) Incompatibility 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine D (Rh) blood            I, II-1, II-3                   A 
 typing and antibody  
 testing of pregnant 
 women at the first visit 
Repeat antibody testing of      II-1                            B 
 all unsensitized D-negative  
 pregnant women at 24-28 
 weeks' gestation 
Routine administration of D  
 immunoglobulin to unsensitized  
 D-negative women 
  Postpartum                    I, II-1                         A 
  At 24-28 weeks' gestation     II-1                            B 
  After amniocentesis or        II-1, II-3                      B 
   induced abortion 
  After CVS, other high-risk*   I, III                          C 
   obstetric procedures or  
   complications 
 
 
Table 39. Intrapartum Electronic Fetal Monitoring 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine intrapartum  
 electronic fetal monitoring 
  Low-risk pregnancies          I                               D 
  High-risk* pregnancies        I                               C 
 
 
Table 40. Home Uterine Activity Monitoring 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
Home uterine activity 
 monitoring 
  Normal risk pregnancies       III                             D 
  High-risk* pregnancies        I, II-2                         C 
 
 
Table 41. Screening for Down Syndrome 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
Offering amniocentesis or       II-2                            B 
 CVS to high-risk*pregnant women 
Offering maternal serum         II-2                            B 
 multiple-marker testing 
 to all pregnant women 
Offering maternal serum         II-2                            C 
 individual marker testing 
 to pregnant women 
Offering midtrimester           II-2, III                       C 
 ultrasound to pregnant women 
 
 
Table 42. Screening for Neural Tube Defects-Including Folate Prophylaxis 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
                                        Screening 
Offering maternal serum         II-2                            B 
 a-fetoprotein measurement 
 to all pregnant women 
Offering midtrimester           I, II-2, III                    C 
 ultrasound to all pregnant 
 women 
                                    Primary Prevention 
Periconceptional folic acid     I                               A 
 4.0 mg daily for women with  
 previous affected pregnancy 
Daily multivitamin or multi-    I, II-2                         A 
 vitamin/multimineral 
 containing 0.4D0.8 mg folic 
 acid for women planning pregnancy 
Daily multivitamin containing   II-2                            B 
 0.4 mg folic acid for women 
 capable of pregnancy 
Dietary folate intake of        II-2                            C 
 0.4 mg/day for women capable 
 of pregnancy 
 
 
Table 43. Screening for Hemoglobinopathies 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Testing for hemoglobin-         I, II-2                         A 
 opathies in newborns 
Offering testing for  
 hemoglobinopathies with 
 counseling 
  Pregnant women at first       II-2, II-3, III                 B 
   prenatal visit 
  High-risk* adolescents and    II-1, III                       C 
   young adults 
 
 
Table 44. Screening for Phenylketonuria 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine measurement of          II-3                            A 
 phenylalanine level on  
 dried-blood spot specimens 
 in newborns 
Routine measurement of blood    II-2, III                       C 
 phenylalanine level in 
 pregnant women 
 
 
Table 45. Screening for Congenital Hypothyroidism 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine measurement of T4       II-3                            A 
 and/or TSH on dried-blood 
 spot specimens in newborns 
 
 
Table 46. Screening for Postmenopausal Osteoporosis 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine bone densitometry       II-2, III                       C 
 in postmenopausal women 
 
 
Table 47. Screening for Adolescent Idiopathic Scoliosis 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine forward-bending         II-3, III                       C 
 test, visual inspection 
 of the back, inclinometer,       
 or other tests in adolescents 
 
 
Table 48. Screening for Dementia 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine use of standardized     III                             C 
 screening tests in elderly 
 persons 
 
 
Table 49. Screening for Depression 
 
Intervention            Level of Evidence           Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine use of standardized     I, II-1                         C 
 screening tests in 
 primary care patients 
 
 
Table 50. Screening for Suicide Risk 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
                                        Screening 
Routine use by primary          I, II-2, II-3                   C 
 care clinicians of direct             
 questions or standardized 
 screening tests in the 
 general population 
                                    Primary Prevention 
Training primary care           II-3                            B 
 clinicians to recognize and                
 treat affective disorders 
 
 
Table 51. Screening for Family Violence 
 
Intervention            Level of Evidence       Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine standardized            III                             C 
 interview or physical           
 exam to detect child abuse 
Routine standardized            III                             C 
 interview to detect elder 
 abuse          
Routine standardized            II-3, III                       C 
 questionnaire to detect                 
 domestic violence 
 
 
Table 52. Screening for Problem Drinking 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine interview or            I, II-2                         B 
 standardized questionnaire 
 to detect problem drinking 
  Adolescents and adults        I, II-2                         B 
  Pregnant women                II-2                            B 
 
 
Table 53. Screening for Drug Abuse 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
Routine screening with          III                             C 
 standardized questionnaires        
 or biologic assays 
 
 
Table 54. Counseling to Prevent Tobacco Use 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
                                   Efficacy of Risk Reduction 
Avoidance or cessation          II-2                            A 
 of tobacco use to reduce  
 the risk of cancer,  
 cardiovascular and respiratory  
 diseases, adverse pregnancy 
 and neonatal outcomes, and 
 effects of passive smoking    
 
        Effectiveness of Counseling and Other Clinical Interventions 
Clinician counseling of         I                               A 
 all patients, including 
 pregnant women, who use 
 tobacco to reduce or stop use      
Nicotine patches or gum as      I                               A 
 an adjunct to counseling   
Clonidine as an adjunct         I                               C 
 to counseling       
Clinician counseling of         III<1>                          C 
 school-aged children and  
 adolescents to avoid tobacco use     
 
<1>Controlled trials have demonstrated the ability of school-based  
intervention programs to delay the initiation of tobacco use in children  
and adolescents. 
 
 
Table 55. Counseling to Promote Physical Activity 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
                                   Efficacy of Risk Reduction 
Regular physical activity       II-2                            A 
 to prevent coronary heart 
 disease, hypertension, 
 obesity, and other diseases     
                                  Effectiveness of Counseling 
Counseling patients to          I, II-2                         C 
 incorporate regular physical 
 activity into their daily routines  
 
 
Table 56. Counseling to Promote a Healthy Diet 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
           Efficacy of Risk Reduction in the General Population 
Limiting intake of dietary      I, II-2, II-3                   A 
 fat (especially saturated fat)       
Limiting intake of dietary      II-2                            B 
 cholesterol 
Emphasizing fruits,             II-2, II-3                      B 
 vegetables and grain  
 products containing fiber    
Maintaining caloric balance     II-2                            B 
 through diet and exercise    
Maintaining adequate intake     I, II-1, II-2, II-3             B 
 of dietary calcium in women     
Reducing intake of dietary      II-3                            C 
 sodium 
Increasing intake of            II-2, II-3, III                 C 
 dietary iron 
Increasing intake of            II-2, II-3                      C 
 beta-carotene and other   
 antioxidants 
Breastfeeding infants           I, II-2                         A 
 
                                Effectiveness of Counseling 
Counseling to change dietary 
 habits 
  Specially trained educators   I<1>                            B 
  Primary care clinicians       III                             C 
 
<1>These trials generally involved specially trained educators such as  
dieticians delivering intensive interventions (e.g., multiple sessions,  
tailored materials) to selected patients with known risk factors. 
 
 
Table 57. Counseling to Prevent Motor Vehicle Injuries 
 
Intervention            Level of Evidence        Strength of Recommendation 
--------------------------------------------------------------------------- 
                                    Efficacy of Risk Reduction 
Child safety seats,             II-2, II-3                      A 
 lap/shoulder belts,   
 and motorcycle helmets 
Avoidance of driving while      II-2, II-3                      A 
 impaired by alcohol or       
 other drugs 
Driver- and passenger-side      II-2                            A 
 air bags 
Alteration of pedestrian        II-1, II-2, II-3                C 
 behavior 
 
                                   Effectiveness of Counseling 
Counseling parents to have      I, II-1, II-2                   B 
 their children use car  
 safety seats or seat belts   
 as appropriate for age 
Counseling adolescent           II-1, II-3                      B 
 and adult patients to use    
 lap/shoulder belts 
Counseling patients to use      III                             C 
 motorcycle helmets      
Counseling problem drinkers     I                               B 
 to reduce their alcohol       
 consumption (see Ch. 52) 
Counseling patients to avoid    III                             C 
 driving while impaired by      
 alcohol or other drugs 
Counseling patients and         III                             C 
 parents of child patients 
 on safe pedestrian behavior 
 
 
Table 58. Counseling to Prevent Household and Recreational Injuries 
 
                                              Level of        Strength of 
Intervention                                  Evidence      Recommendation 
--------------------------------------------------------------------------- 
                        Efficacy of Risk Reduction 
Fires and Burns 
 Properly installed/tested smoke detectors      II-2            B 
 Smoking cessation (see Ch. 54)                 II-2            A 
 Flame-retardant sleepwear for children         II-3            A 
 Hot water heaters set to <120-130deg. F        II-3            A 
Drowning 
 Four-foot, four-sided isolation fences with    II-2            B 
  self-latching gates  
 Cardiopulmonary resuscitation (CPR)            II-2, III       B 
  training     
Poisonings 
 Child-proof containers for medications         II-3            A 
 Limitation of number of tablets packaged       II-3            A 
 Poison-warning stickers designed for           II-1            D 
  children (e.g., "Mr. Yuk" stickers)  
Bicycling and ATV Injuries 
 Approved bicycle and ATV helmets               II-2, II-3      A 
 Avoidance of bicycling near traffic            II-2, III       B 
 ATVs with smaller engines and 4 wheels         II-2            B 
 Training in safe bicycling behavior            I, III          C 
Alcohol-Related Injuries 
 Avoidance of swimming, boating, bicycling,     II-2            B 
  hunting, or smoking while intoxicated            
Falls in Children 
 Window guards in high-risk*                    II-3            A 
  buildings    
Falls in Elderly Persons 
 Exercise, especially balance training          I, II-1, II-2   B 
 Home-based multifactorial fall prevention      I, II-2         B 
  interventions in high-risk* elders   
 External hip protectors in institutionalized   II-1            C 
  elderly persons      
 Other Injury Prevention Measures               III             C 
 (see Ch. 58 for details)      
 
                        Effectiveness of Counseling 
Counseling parents of young children on         I, II-1,        B 
 measures to reduce injury risk                 II-2, II-3 
Counseling adolescents and adults on            I, III          C 
 measures to reduce injury risk           
Counseling problem drinkers to reduce           I               B 
 alcohol consumption (see Ch. 52)         
Counseling elderly patients to address risk     I               C 
 factors for falls    
 
*See relevant chapter for definition of high risk. 
 
 
Table 59.  Counseling to Prevent Youth Violence 
 
Intervention                            Level of              Strength of  
                                        Evidence             Recommendation 
--------------------------------------------------------------------------- 
                        Efficacy of Risk Reduction 
Removal or safe storage of              II-2, II-3, III         B 
 firearms in the home     
Acquisition of interpersonal -          II-2, III               C 
 problem solving skills           
Reduction of heavy or problem           II-2, II-3, III         B 
 drinking     
Reduction of illicit drug use or        II-2, III               C 
 drug trafficking     
 
                        Effectiveness of Counseling 
Counseling problem drinkers to reduce   I                       B 
 alcohol consumption (see Ch. 52)     
Counseling on measures to reduce        III                     C 
 violence risk        
 
 
Table 60. Counseling to Prevent Low Back Pain 
 
                                                                Strength of 
Intervention                            Level of Evidence     Recommendation 
--------------------------------------------------------------------------- 
                                Efficacy of Risk Reduction 
Exercise to strengthen back or          I, II-1, II-2               C 
 abdominal muscles or to  
 improve overall fitness   
Corsets/back belts                      I, II-2                     C 
Modification of risk factors (smoking,  II-2, III                   C 
 obesity, psychological factors) 
 
                                Effectiveness of Counseling 
Back pain prevention education 
 Workplace                              I, II-1, II-2               C 
 Pregnant women                         II-1                        C 
 Primary care patients                  III                         C 
 
 
Table 61. Counseling to Prevent Dental and Periodontal Disease 
 
                                                              Strength of 
Intervention                            Level of Evidence    Recommendation 
--------------------------------------------------------------------------- 
                                Efficacy of Risk Reduction 
Regular visits to dental care provider (for     I                  B 
 services such as professionally applied  
 topical fluorides, sealants)          
Toothbrushing with fluoride-containing          I, III             B 
 toothpaste   
Dental flossing                                 II-1               B 
Avoidance of putting infants and children       II-2, III          B 
 to bed with a bottle         
Reduced and less frequent intake of             II-2               C 
 sugary foods         
Fluoride supplementation of persons             II-1               A 
 aged <16 yr, in areas with inadequate  
 water fluoridation    
 
                                Effectiveness of Counseling 
Counseling patients (parents) to follow         II-2, II-3         C 
 measures to reduce their (their  
 children's) risk of oral disease  
 
 
Table 62. Counseling to Prevent HIV Infection and Other Sexually Transmitted  
Diseases 
 
                                                              Strength of 
Intervention                            Level of Evidence    Recommendation 
--------------------------------------------------------------------------- 
                                Efficacy of Risk Reduction 
Sexual abstinence or maintenance of             II-2               A 
 mutually faithful monogamous sexual  
 relationship 
Regular use of condoms                          II-2, II-3         A 
Regular use of female barrier                   I<1>, II-2         B 
 contraceptives and spermicides       
Avoidance of contaminated injection             II-2               A 
 equipment    
 
                                Effectiveness of Counseling 
Counseling by primary care clinicians to        I, II-2            C 
 reduce high-risk* sexual behavior or  
 injection drug use 
 
<1>Benefit demonstrated for gonorrhea and chlamydia, but effects on HIV  
infection uncertain. 
*See relevant chapter for definition of high risk. 
 
 
Table 63.  Counseling to Prevent Unintended Pregnancy 
 
                                                              Strength of 
Intervention                            Level of Evidence    Recommendation 
--------------------------------------------------------------------------- 
                                Efficacy of Risk Reduction 
Sexual abstinence or regular                    II-2              A 
 use of contraceptives            
 
                                Effectiveness of Counseling 
Clinician counseling to improve                 II-3              B 
 the effective use of contraceptives 
Clinician counseling to promote                 III               C 
 sexual abstinence among adolescents  
 
 
Table 64. Counseling to Prevent Gynecologic Cancers 
 
                                                              Strength of 
Intervention                            Level of Evidence    Recommendation 
--------------------------------------------------------------------------- 
                                Efficacy of Risk Reduction 
Oral contraceptives to prevent                  II-2              B 
 ovarian and endometrial cancer 
Avoidance of high-risk* sexual                  II-2              A 
 activity, use of barrier contra-            
 ceptives and spermicides to  
 prevent cervical cancer 
Tubal sterilization to prevent                  II-2              B 
 ovarian cancer 
 
                                Effectiveness of Counseling 
Counseling about measures to                    III               C 
 reduce risk of gynecologic  
 cancers 
 
 
Table 65. Childhood Immunizations<1> 
 
                                                              Strength of 
Intervention                            Level of Evidence    Recommendation 
--------------------------------------------------------------------------- 
                                Routine Childhood Immunizations 
Diphtheria  \\ 
Pertussis     \\ 
Tetanus         \\ 
Poliomyelitis     \\                            I, II-3              A  
Measles           // 
Rubella         // 
Mumps         // 
H. influenzae type b conjugate                  I, II-1, II-2, II-3  A 
Hepatitis B                                     I, II-2, II-3        A 
Varicella                                       I, II-3              A 
 
                            Immunizations for High-Risk* Children 
Hepatitis A (age 32 yr)                         I, II-3              A 
Influenza (age 36 mo) (see Ch. 66)              II-2                 B 
Pneumococcus (age 32 yr) (see Ch. 66)  
 Immunocompetent                                I, II-2              B 
 Immunocompromised                              I, II-2              C 
Healthy persons living in epidemic              I                    A 
 conditions       
                            Chemoprophylaxis Against Influenza A 
Amantadine/rimantadine -                        I                    B 
 for high risk* children  
 (see Ch. 66)  
 
<1>See Ch. 25 for recommendations on the use of BCG vaccine against  
tuberculosis. 
 
 
Table 66. Adult Immunizations-Including Chemoprophylaxis Against Influenza A 
 
                                                              Strength of  
Intervention                            Level of Evidence    Recommendation 
--------------------------------------------------------------------------- 
                                Routine Adult Immunizations 
Influenza (age 365 yr)                          I, II-2         B 
Pneumococcus (age 365 yr)                       II-2            B 
Tetanus-diphtheria                              I, II-3         A 
Hepatitis B (young adults)                      I, II-3         A 
 
                            Immunizations for High-Risk* Adults 
Influenza                                       II-2            B 
Pneumococcus 
 Immunocompetent                                I, II-2         B 
 Immunocompromised                              I, II-2         C 
Healthy young adults living                     I               A 
 in epidemic conditions   
Hepatitis B                                     I, II-3         A 
Hepatitis A                                     I               B 
Measles-mumps-rubella                           I               A 
Measles-mumps-rubella (second dose)             II-2, II-3      B 
Varicella (see Ch. 65)                          I, II-3         B 
 
                        Chemoprophylaxis Against Influenza A 
Amantadine/rimantadine 
for high-risk* adults                           I               B 
 
 
Table 67. Postexposure Prophylaxis for Selected Infectious Diseases 
 
                                                Level of    Strength of 
Disease                 Intervention            Evidence   Recommendation 
--------------------------------------------------------------------------- 
H. influenzae type b    Rifampin                I, II-3         A 
Hepatitis A             Immune globulin         II-1            A 
Hepatitis B             Immune globulin/vaccine I               A 
N. meningitidis         Rifampin                I, II-1         A 
                        Vaccine<1>              I, II-1, II-3   A 
                        Ceftriaxone             I               C<2> 
Rabies                  Immune globulin/        I, II-3         A 
                        postexposure vaccine 
                        Preexposure vaccine     II-1            A 
                        in high-risk* persons 
Tetanus                 Vaccine/immune          II-1,II-2,II-3  A 
                        globulin 
 
<1>Persons 33 mo in serogroup A outbreaks; persons 32 yr in serogroup C, Y, and  
W135 outbreaks. 
<2>The efficacy of ceftriaxone in eliminating pharyngeal carriage of  
meningococcus has been confirmed only for serogroup A strains. 
 
 
Table 68. Postmenopausal Hormone Prophylaxis 
 
                                                          Strength of  
Intervention                        Level of Evidence   Recommendation 
--------------------------------------------------------------------------- 
Routinely counseling peri- and          I, II-2                 B 
 postmenopausal women about the risks  
 and benefits1 of hormone prophylaxis  
 
<1>Hormone prophylaxis reduces the risk of osteoporosis and coronary heart  
disease, but may increase the risk of endometrial and breast cancer. 
 
 
Table 69. Aspirin Prophylaxis for the Primary Prevention of Myocardial  
Infarction 
                                                        Strength of 
Intervention                    Level of Evidence     Recommendation 
--------------------------------------------------------------------------- 
Routine aspirin prophylaxis 
 Middle-aged or older men               I                    C 
 Middle-aged women                      II-2                 C 
 
 
Table 70. Aspirin Prophylaxis in Pregnancy 
                                                Level of       Strength of  
Intervention                                    Evidence     Recommendation 
--------------------------------------------------------------------------- 
Routine aspirin prophylaxis to prevent  
 preeclampsia 
  Pregnant women                                    I                 C 
  High-risk* pregnant women                         I                 C 
Routine aspirin prophylaxis to prevent  
 intrauterine growth retardation in  
  High-risk* pregnant women                         I, II-1           C