The Guide to Clinical

Preventive Services

2010 - 2011

Recommendations of the

U.S. Preventive

Services Task Force
The Guide to Clinical

Preventive Services

2010 - 2011

Recommendations of the

U.S. Preventive Services Task Force
The recommendation statements in this Guide are

abridged. To view the full recommendation statements or

recommendation statements published after March 2010,

go to http://www.USPreventiveServicesTaskForce.org.

The U.S Preventive Services Task Force’s (USPSTF)

Electronic Preventive Services Selector (ePSS) allows

users to download the USPSTF recommendations to

PDA or mobile devices, receive notifications of updates,

and search and browse recommendations online. Users

can search the ePSS for recommendations by patient age,

sex, and pregnancy status. To download, subscribe, or

search, go to http://epss.ahrq.gov.

Recommendations made by the USPSTF are

independent of the U.S. Government. They should not

be construed as an official position of AHRQ or the U.S.

Department of Health and Human Services.
iii

Foreword

Since 1998, the Agency for Healthcare Research and

Quality (AHRQ) has convened the U.S. Preventive

Services Task Force (USPSTF)—an independent panel

of private-sector experts in prevention and primary

care. AHRQ staff provide scientific, technical, and

administrative support for the Task Force, and assist in

disseminating its findings and recommendations to key

audiences.

In that role, we are pleased to make The Guide to

Clinical Preventive Services 2010-2011 available to

those who seek to ensure that their patients receive the

highest quality clinical preventive services.

Findings and recommendations from the Guide are

routinely used in a variety of settings to improve the

preventive care that patients receive. For example, a

computer-aided screening initiative based on the

recommendations and delivered via an online annual

Health Risk Assessment has been successfully

implemented for employees at IBM Integrated Health

Services. Also, an education and training program for

physician assistants at the University of North Texas

Health Science Center in Fort Worth is using the

Guide as a tool for student research on clinical

preventive services.
Foreword

iv

In addition, the USPSTF recommendations are

valuable tools that can help you and your patients have

a conversation about which clinical preventive services

are best for them.

As more information becomes available to clinicians

and patients alike, AHRQ’s goal is to help improve

patients’ health and well being, and contribute to

better health outcomes for the Nation overall.

Carolyn M. Clancy, M.D.

Director

Agency for Healthcare Research and Quality
v

Preface

Since being codified by Congress in 1984, the U.S.

Preventive Services Task Force (USPSTF) has been

fulfilling its charge to conduct rigorous reviews of

research evidence to create evidence-based

recommendations for preventive services that should

be provided in the primary care setting.

Over this quarter century of work, the USPSTF

has made and maintained more than 67 separate

recommendations covering services that are intended

to improve health outcomes from heart disease,

cancer, infectious diseases, and other conditions and

events that impact the health of children, adolescents,

adults, and pregnant women. The Guide to Clinical

Preventive Services 2010-2011 is a compilation of

abridged USPSTF recommendations, both new and

updated, released from 2002 to 2010 and can be used

as an evidence-based tool at the point of patient care.

Recommendations that were being updated while this

edition of the Guide was being compiled, as well as

the complete USPSTF recommendation statements,

are available along with their supporting scientific

evidence at http://www.USPreventiveServices

TaskForce.org.

The use of these recommendations has evolved

over time. The suggestion that it is not beneficial to

provide all of the services available for prevention was

nearly a heretical concept in U.S. medical practice

when the first USPSTF started its work. Over time,

individual health care providers, professional
organizations, integrated health systems, health plans

and insurers, and public programs, including the

Centers for Medicare & Medicaid Services as well as

groups crafting health quality measures and national

health objectives, have adopted the recommendations.

The primary audience for the USPSTF’s work remains

primary care clinicians, and the recommendations are

now considered by many to provide definitive

standards for preventive services.

Another exciting development is that the work of

the USPSTF is central to the preventive benefits

covered under the Patient Protection and Affordable

Care Act. Under the new law, preventive services with

a Task Force grade of A or B will be covered under new

health insurance plans or policies. Even prior to

national reform activities, the USPSTF committed to

increasing the transparency of our work, and these

efforts gained additional momentum in view of the

enhanced importance of the recommendations under

the new law. The USPSTF now employs an Internetbased public comment process to assist us in better

crafting messages for the public and in considering

additional input from experts and advocates. With

these changes, though, the USPSTF remains

committed to evaluating evidence free from the

influence of politics, special interests, and advocacy.

Our methods continue to evolve as well. Our

Procedure Manual, which can be found at http://

www.USPreventiveServicesTaskForce.org/uspstf08/

methods/procmanual.htm, outlines our updated

process for evaluating the quality and strength of the

vi

Preface
Preface

evidence for a service, determining the net health

benefit (benefit minus harms) associated with the

service, and judging the level of certainty that

providing these services in primary care will realize the

expected level of benefit. We continue to explore the

appropriate use of mathematical modeling on filling in

research gaps regarding the ages at which to start and

stop providing a service, and at what time intervals. In

addition, we are committed to improving the

communication of our recommendations to a broader

audience, including patients and policymakers.

As before, the letter grade linked to each

recommendation reflects the magnitude of net benefit

and the strength and certainty of the evidence

supporting the provision of a specific preventive

service. These grades translate to practice guidance for

clinicians:

• Discuss services with “A” and “B”

recommendations with eligible patients and offer

them as a priority.

• Discourage the use of services with “D”

recommendations unless there are unusual

additional considerations.

• Give lower priority to services with “C”

recommendations; they need not be provided

unless there are individual considerations in favor of

providing the service.

• Carefully read the Clinical Considerations section

for guidance for services with “I” statements, and

vii
help patients understand the uncertainty

surrounding these services since the evidence is

insufficient to determine net benefit.

As is true of all patient care, preventive services

have become much more complex in view of ongoing

research. The USPSTF realizes that clinical decisions

about patients involve more complex considerations

than the evidence alone; clinicians should always

understand the evidence but individualize

decisionmaking to the specific patient and situation.

While providers and patients look for simple messages

and actions, our recommendations reflect the

advances in knowledge in this critical area of health

services, and, in order to maximize the health benefit

and decrease any health harms, we must consider the

new complexity as we do for all medical services we

provide. The Clinical Considerations section of each

USPSTF recommendation statement helps clinicians

by offering practical information so they can tailor

these recommendations to individual patients.

I strongly encourage clinicians to visit the USPSTF

Web site and read the complete recommendation

statements for those services they provide, as the

additional information can help them deliver the

highest quality preventive care. In addition, the

USPSTF Electronic Preventive Services Selector

(ePSS), available via PDA or on the Web at

http://epss.ahrq.gov, allows users to search USPSTF

recommendations by patient age and other clinical

characteristics.

viii

Preface
I hope you find The Guide to Clinical Preventive

Services 2010-2011 to be a useful tool as you care for

patients. Based on the best medical evidence

available, I am confident that by implementing these

recommended services, you will help your patients

live longer and healthier lives.

Ned Calonge, M.D., M.P.H.

Chair, U.S. Preventive Services Task Force

ix

Preface
x
Contents

Foreword ................................................................iii

Preface .....................................................................v

Section 1. Preventive Services Recommended

by the USPSTF....................................................1

Section 2. Recommendations for Adults...............11

Cancer...............................................................13

Aspirin/NSAIDS for Prevention of

Colorectal Cancer........................................13

Bladder Cancer in Adults, Screening................15

Breast and Ovarian Cancer Susceptibility,

Genetic Risk Assessment, and BRCA

Mutation Testing ........................................16

Breast Cancer, Chemoprevention.....................20

*Breast Cancer, Screening (2009).....................21

Breast Cancer, Screening (2002) ......................28

Cervical Cancer, Screening...............................31

Colorectal Cancer, Screening ...........................36

Lung Cancer Screening ....................................41

Oral Cancer, Screening ....................................43

Ovarian Cancer, Screening...............................45

Pancreatic Cancer, Screening............................47

Prostate Cancer, Screening ...............................48

Skin Cancer, Counseling to Prevent.................51

Skin Cancer, Screening.....................................52

Testicular Cancer, Screening.............................54

Vitamin Supplementation to Prevent Cancer

and Cardiovascular Disease, Routine...........56

xi
Heart, Vascular, and Respiratory Diseases........57

Abdominal Aortic Aneurysm, Screening ..........57

Aspirin for the Prevention of Cardiovascular

Disease........................................................61

Carotid Artery Stenosis, Screening...................73

Chronic Obstructive Pulmonary Disease,

Screening .....................................................75

Coronary Heart Disease, Screening..................77

*Coronary Heart Disease Risk Assessment,

Nontraditional Risk Factors.........................80

High Blood Pressure, Screening .......................84

Lipid Disorders in Adults, Screening................86

Peripheral Arterial Disease, Screening ..............91

Infectious Diseases............................................93

Asymptomatic Bacteriuria, Screening...............93

Chlamydial Infection, Screening ......................95

Genital Herpes, Screening................................99

Gonorrhea, Screening ....................................102

Hepatitis B Virus Infection, Screening...........106

*Hepatitis B Virus Infection in Preganancy

Screening ...................................................108

Hepatitis C in Adults, Screening....................110

HIV, Screening...............................................112

Sexually Transmitted Infections,

Counseling.................................................116

Syphilis Infection, Screening ..........................119

Syphilis Infection in Pregnancy, Screening .....122

Injury and Violence ........................................125

Family and Intimate Partner Violence,

Screening ...................................................125

xii

Contents
Motor Vehicle Occupant Restraints and

Avoidance of Alcohol Use While Driving,

Counseling.................................................128

Mental Health Conditions and Substance

Abuse ..........................................................131

Alcohol Misuse, Screening and Behavioral

Counseling Interventions in Primary Care

to Reduce...................................................131

*Depression (Adults), Screening.....................136

Illicit Drug Use, Screening.............................143

Suicide Risk, Screening .................................146

*Tobacco and Tobacco-caused Disease (Adults

and Pregnant Women) Counseling and

Interventions..............................................148

Metabolic, Nutritional, and Endocrine

Conditions..................................................151

Diet, Behavioral Counseling in Primary

Care to Promote a Healthy........................151

*Folic Acid to Prevent Neural Tube Defects...152

Hemochromatosis, Screening.........................154

Hormone Therapy for the Prevention of

Chronic Conditions in Postmenopausal

Women......................................................157

Iron Deficiency Anemia, Screening................160

Obesity in Adults, Screening..........................163

Physical Activity, Behavioral Counseling in

Primary Care to Promote...........................168

Thyroid Disease, Screening............................169

Type 2 Diabetes Mellitus in Adults,

Screening ...................................................171

xiii

Contents
Musculoskeletal Conditions............................175

Osteoporosis Screening ..................................175

Obstetric and Gynecologic Conditions...........179

Bacterial Vaginosis in Pregnancy, Screening ...179

Breastfeeding, Primary Care Interventions

to Promote.................................................181

Gestational Diabetes Mellitus, Screening .......183

Rh (D) Incompatibility, Screening .................185

Vision Disorders .............................................187

Glaucoma, Screening .....................................187

*Impaired Visual Acuity in Older Adults,

Screening ...................................................190

Section 3. Recommendations for Children

and Adolescents..........................................193

Blood Lead Levels in Children and

Pregnant Women, Screening......................195

Congenital Hypothyroidism, Screening .........199

Hip Dysplasia, Screening ...............................201

Hyperbilirubinemia in Infants, Screening

to Prevent Chronic Bilirubin

Encephalopathy .........................................203

Idiopathic Scoliosis in Adolescents,

Screening ...................................................206

Lipid Disorders in Children, Screening..........208

Major Depressive Disorder in Children

and Adolescents, Screening........................211

Newborn Hearing, Screening.........................213

xiv

Contents
*Obesity in Children and Adolescents,

Screening ...................................................215

Phenylketonuria, Screening............................218

Sickle Cell Disease, Screening ........................219

Speech and Language Delay in Preschool

Children, Screening ...................................221

Tobacco Use and Tobacco-caused Disease

(Children and Adolescents), Counseling

to Prevent ..................................................223

Visual Impairment in Children Younger

Than Age 5 Years, Screening......................224

Appendixes and Index.....................................227

Appendix A. How the U.S. Preventive

Services Task Force Grades Its

Recommendations.....................................228

Appendix B. Members of the U.S. Preventive

Services Task Force 2002-2010..................234

Appendix C. Acknowledgments.....................238

Appendix D. ACIP Recommended

Immunization Schedules............................243

Index. Recommendations, Alphabetical by

Topic..........................................................267

*New recommendations released March 2009 to

March 2010.

xv

Contents
Section 1.

Preventive Services

Recommended by the

USPSTF

All recommendation statements in this Guide are

abridged. To see the full recommendation statements

and recommendations published after March 2010,

go to http://www.USPreventiveServicesTaskForce.org.
Pre

v

entiv

e

S

ervices R

eco

m

m

end

e

d

b

y the

U

S

P

S

T

F

The U.S. Preventive Services Task Force (USPSTF) recom

mends that clinicians discuss these preventive services with eligible patients and offer them as a priority. All these services have received an “A” or a “B” (recom

mended) grade from the Task Force.

For definitions of all grades used by the USPSTF, see Appendix A (beginning on p. 228). The full listings of all USPSTF recom

mendations for adults and children are in Section 2 (beginning on p. 11) and Section 3 (beginning on P. 193).

Ad

ults Special Populations

Recom

men

dation

Men

Women

Pregnant Women

C

hildren

Abdominal Aortic Aneurysm, Screening1 3

Alcohol Misuse Screening an

d

Behavioral

Cou

nseling Interventions 3

3

3

Aspirin for the Prevention of

Cardiovascular Disease

2 3

3

Asymptomatic Bacteriuria in

Ad

ults,

Screening3 3

Breast Cancer, Screening4 3

3

Recommended Preventive Services

continued
Preventive Services Recommended by the USPSTF (continued)

Adults Special Populations

Recommendation Men Women Pregnant Women Children

Breast and Ovarian Cancer Susceptibility,

Genetic Risk Assessment and BRCA

Mutation Testing5 3

Breastfeeding, Primary Care

Interventions to Promote6 3 3

Cervical Cancer, Screening7 3

Chlamydial Infection, Screening8 3 3

Colorectal Cancer, Screening9 3 3

Congenital Hypothyroidism, Screening10 3

Depression (Adults), Screening11 3 3

continued

RecommendedPreventiveServices

4
Ad

ults Special Populations

Recom

men

dation

Men

Women

Pregnant Women

C

hildren

Folic Acid Supplementation12 3

Gonorrhea, Screening13 3Gonorrhea, Prophylactic Medication14 3

Hearing Loss in

Newborns, Screening15 3

Hepatitis B

Virus Infection, Screening16 3

High

Blood

Pressure, Screening 3

3

HIV, Screening17 3

3

3

3

Iron

Deficiency

Anemia, Prevention18 3

Iron

Deficiency

Anemia, Screening19 3

Lipid

Disorders in

Ad

ults, Screening20 3

3

continued

Recommended Preventive Services

5
Pre

v

entiv

e

S

ervic

es R

e

c

o

m

m

end

e

d

b

y the

U

S

P

S

T

F (c

o

ntin

u

e

d)

Ad

ults Special Populations

Recom

men

dation

Men

Women

Pregnant Women

C

hildren

Major Depressive Disorder in

C

hildren

an

d

Adolescents, Screening21 3

Obesity in

Ad

ults, Screening22 3

3

Obesity in

C

hildren an

d

Adolescents,

Screening23 3

Osteoporosis, Screening24 3

P

henylketon

uria, Screening25 3

Rh (D) Incompatibility, Screening26 3

Sexually

Transmitted Infections, Counseling27 3

3

3

Sickle Cell Disease, Screening28 3

continued

Recommended Preventive Services

6
Pre

v

entiv

e

S

ervic

es R

e

c

o

m

m

end

e

d

b

y the

U

S

P

S

T

F (c

o

ntin

u

e

d)

Ad

ults Special Populations

Recom

men

dation

Men

Women

Pregnant Women

C

hildren

Syphilis Infection, Screening29 3

3

3

Tobacco Use an

d

Tobacco-Caused

Disease,

Cou

nseling an

d Interventions

30 3

3

3

Type 2 Diabetes Mellitus in

Ad

ults,

Screening31 3

3

Visual Impairment in

C

hildren

You

nger

than

Age 5 Years, Screening32 3

Recommended Preventive Services

7
1

One-time screening by ultrasonography in men aged

65 to 75 who have ever smoked.

2

When the potential harm of an increase in

gastrointestinal hemorrhage is outweighed by a

potential benefit of a reduction in myocardial

infarctions (men aged 45-79 years) or in ischemic

strokes (women aged 55-79 years).

3

Pregnant women at 12-16 weeks gestation or at first

prenatal visit, if later.

4

Biennial screening mam

mography for women aged

50 to 74 years. See Sum

mary of 2002

Recom

mendations for information about the

Affordable Health Care Act.

5

Refer women whose family history is associated with

an increased risk for deleterious mutations in BR

CA1

or BR

CA2 genes for genetic counseling and

evaluation for BR

CA testing.

6

Interventions during pregnancy and after birth to

promote and support breastfeeding.

7

Women aged 21-65 who have been sexually active

and have a cervix.

8

Sexually active women 24 and younger and other

asymptomatic women at increased risk for infection.

Asymptomatic pregnant women 24 and younger and

others at increased risk.

9

Adults aged 50-75 using fecal occult blood testing,

sigmoidoscopy, or colonoscopy.

10

Newborns.

11

When staff-assisted depression care supports are in

place to assure accurate diagnosis, effective treatment,

and follow-up.

12

All women planning or capable of pregnancy take a

daily supplement containing 0.4 to 08. mg (400 to

800 μg) of folic acid.

13

Sexually active women, including pregnant women

25 and younger, or at increased risk for infection.14

Prophylactic ocular topical medication for all

newborns against gonococcal ophthalmia

neonatorum.

15

Newborns.

16

Pregnant women at first prenatal visit.

Recommended Preventive Services

8
17

All adolescents and adults at increased risk for HIV

infection and all pregnant women.

18

Routine iron supplementation for asymptomatic

children aged 6 to 12 months who are at increased

risk for iron deficiency anemia.

19

Routine screening in asymptomatic pregnant

women.

20

Men aged 20-35 and women over age 20 who are

at increased risk for coronary heart disease; all men

aged 35 and older.

21

Adolescents (age 12-18) when systems are in place

to ensure accurate diagnosis, psychotherapy, and

follow-up.

22

Intensive counseling and behavioral interventions

to promote sustained weight loss for obese adults.

23

Screen children aged 6 years and older for obesity

and offer them or refer them to comprehensive,

intensive behavioral interventions to promote

improvement in weight status.

24

Women 65 and older and women 60 and older at

increased risk for osteoporotic fractures.

25

Newborns.

26

Blood typing and antibody testing at first

pregnancy-related visit. Repeated antibody testing for

unsensitized Rh (D)-negative women at 24-28 weeks

gestation unless biological father is known to be Rh

(D) negative.

27

All sexually active adolescents and adults at

increased risk for STIs.

28

Newborns

29

Persons at increased risk and all pregnant women.

30

Ask all adults about tobacco use and provide

tobacco cessation interventions for those who use

tobacco; provide augmented, pregnancy-tailored

counseling for those pregnant women who smoke.

31

Asymptomatic adults with sustained blood pressure

greater than 135/80 mg Hg.

32

To detect amblyopia, strabismus, and defects in

visual acuity.

Recommended Preventive Services

9
Section 2.

Recommendations

for Adults

All recommendation statements in this Guide are

abridged. To see the full recommendation statements

and recommendations published after March 2010,

go to http://www.USPreventiveServicesTaskForce.org.
Clinical Considerations

n This recommendation applies to asymptomatic

adults at average risk for colorectal cancer, including

those with a family history of colorectal cancer, and

not to individuals with familial adenomatous

polyposis, hereditary nonpolyposis colon cancer

syndromes (Lynch I or II), or a history of colorectal

cancer or adenomas.

n Clinicians should continue to discuss aspirin

chemoprophylaxis with patients who are at

increased risk for coronary heart disease, but there is

good evidence that low-dose aspirin used to prevent

coronary heart disease (CHD) events in those at

increased risk for CHD does not lead to a reduced

13

Cancer

Aspirin or Nonsteroidal Antiinflammatory Drugs for the Primary

Prevention of Colorectal Cancer

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against the routine use of

aspirin and nonsteroidal anti-inflammatory drugs

(NSAIDs) to prevent colorectal cancer in

individuals at average risk for colorectal cancer.

Grade: D Recommendation.
Primary Prevention of Colorectal Cancer

14

incidence of colorectal cancer. Aspirin use by

patients at increased risk for coronary heart disease

has been shown to reduce all-cause mortality. The

evidence and recommendation statements from the

USPSTF for aspirin chemoprophylaxis can be

found on the USPSTF Web site

(http://www.USPreventiveServicesTaskForce.org).

n More than 80% of colorectal cancers arise from

adenomatous polyps. However, most adenomatous

polyps will not progress to cancer. Age represents a

major risk factor for colorectal cancer, with

approximately 90% of cases occurring after age 50

years. Thirty to fifty percent of Americans older

than age 50 will develop adenomatous polyps.

Between 1% and 10% of these polyps will progress

to cancer in 5 to 10 years. The risk for a polyp

developing into cancer depends on the villous

architecture, degree of cytologic dysplasia, size, and

total number of polyps.

n All persons older than age 50 who are at average

risk for colorectal cancer should be screened for

colorectal cancer regardless of their aspirin or

NSAID use. The USPSTF recommendation on

screening for colorectal cancer can be accessed at

http://www.USPreventiveServicesTaskForce.org.

This USPSTF recommendation was first published in:

Ann Intern Med. 2007; 146(5):361-64.
NOTE: The USPSTF was updating its

recommendation on this topic during publication

of The Guide to Clinical Preventive Services 2010-

2011. For the most recent recommendation, please

visit the USPSTF Web site at:

http://www.USPreventiveServicesTaskForce.org or

the USPSTF’s Electronic Preventive Services

Selector (ePSS) at http://epss.ahrq.gov. You can

search the ePSS for recommendations by patient

age, sex, and pregnancy status, and you can

download the recommendations as well as receive

automatic updates to your PDA.

15

Screening for Bladder Cancer

in Adults
Clinical Considerations

n These recommendations apply to women who have

not received a diagnosis of breast or ovarian cancer.

They do not apply to women with a family history

of breast or ovarian cancer that includes a relative

with a known deleterious mutation in BRCA1 or

BRCA2 genes; these women should be referred for

genetic counseling. These recommendations do not

apply to men.

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine referral for

genetic counseling or routine breast cancer

susceptibility gene (BRCA) testing for women

whose family history is not associated with an

increased risk for deleterious mutations in breast

cancer susceptibility gene 1 (BRCA1) or breast

cancer susceptibility gene 2 (BRCA2). Grade: D

Recommendation.

The USPSTF recommends that women whose

family history is associated with an increased risk

for deleterious mutations in BRCA1 or BRCA2

genes be referred for genetic counseling and

evaluation for BRCA testing. Grade: B

Recommendation.

16

Genetic Risk Assessment and BRCA

Mutation Testing for Breast and

Ovarian Cancer Susceptibility
17

BRCA Mutation Testing

n Although there currently are no standardized referral

criteria, women with an increased-risk family history

should be considered for genetic counseling to

further evaluate their potential risks.

n Certain specific family history patterns are associated

with an increased risk for deleterious mutations in

the BRCA1 or BRCA2 gene. Both maternal and

paternal family histories are important. For nonAshkenazi Jewish women, these patterns include 2

first-degree relatives with breast cancer, 1 of whom

received the diagnosis at age 50 years or younger; a

combination of 3 or more first- or second-degree

relatives with breast cancer regardless of age at

diagnosis; a combination of both breast and ovarian

cancer among first- and second-degree relatives; a

first-degree relative with bilateral breast cancer; a

combination of 2 or more first- or second-degree

relatives with ovarian cancer regardless of age at

diagnosis; a first- or second-degree relative with both

breast and ovarian cancer at any age; and a history of

breast cancer in a male relative.

n For women of Ashkenazi Jewish heritage, an

increased-risk family history includes any first-degree

relative (or 2 second-degree relatives on the same

side of the family) with breast or ovarian cancer.

n About 2 percent of adult women in the general

population have an increased-risk family history as

defined here. Women with none of these family

history patterns have a low probability of having a

deleterious mutation in BRCA1 or BRCA2 genes.
n Computational tools are available to predict the risk

for clinically important BRCA mutations (that is,

BRCA mutations associated with the presence of

breast cancer, ovarian cancer, or both), but these

tools have not been verified in the general

population. There is no empirical evidence

concerning the level of risk for a BRCA mutation

that merits referral for genetic counseling.

n Not all women with a potentially deleterious BRCA

mutation will develop breast or ovarian cancer. In a

woman who has a clinically important BRCA

mutation, the probability of developing breast or

ovarian cancer by age 70 years is estimated to be 35

percent to 84 percent for breast cancer and 10

percent to 50 percent for ovarian cancer.

n Appropriate genetic counseling helps women make

informed decisions, can improve their knowledge

and perception of absolute risk for breast and

ovarian cancer, and can often reduce anxiety. Genetic

counseling includes elements of counseling; risk

assessment; pedigree analysis; and, in some cases,

recommendations for testing for BRCA mutations in

affected family members, the presenting patient, or

both. It is best delivered by a suitably trained health

care provider.

n A BRCA test is typically ordered by a physician.

When done in concert with genetic counseling, the

test assures the linkage of testing with appropriate

management decisions. Genetic testing may lead to

potential adverse ethical, legal, and social

consequences, such as insurance and employment

18

BRCA Mutation Testing
discrimination; these issues should be discussed in

the context of genetic counseling and evaluation for

testing.

n Among women with BRCA1 or BRCA2 mutations,

prophylactic mastectomy or oophorectomy

decreases the incidence of breast and ovarian cancer;

there is inadequate evidence for mortality benefits.

Chemoprevention with selective estrogen receptor

modulators may decrease incidence of estrogen

receptor-positive breast cancer; however, it is also

associated with adverse effects, such as pulmonary

embolism, deep venous thrombosis, and

endometrial cancer. Most breast cancer associated

with BRCA1 mutations is estrogen receptor-negative

and thus is not prevented by tamoxifen. Intensive

screening with mammography has poor sensitivity,

and there is no evidence of benefit of intensive

screening for women with BRCA1 or BRCA2 gene

mutations. Magnetic resonance imaging (MRI) may

detect more cases of cancer, but the effect on

mortality is not clear.

n Women with an increased-risk family history are at

risk not only for deleterious BRCA1 or BRCA2

mutations but potentially for other unknown

mutations as well. Women with an increased-risk

family history who have negative results on tests for

BRCA1 and BRCA2 mutations may also benefit

from surgical prophylaxis.

This USPSTF recommendation was first published in:

Ann Intern Med. 2005; 143:355-361.

19

BRCA Mutation Testing
NOTE: The USPSTF was updating its

recommendation on this topic during publication

of The Guide to Clinical Preventive Services 2010-

2011. For the most recent recommendation, please

visit the USPSTF Web site at:

http://www.USPreventiveServicesTaskForce.org or

the USPSTF’s Electronic Preventive Services

Selector (ePSS) at http://epss.ahrq.gov. You can

search the ePSS for recommendations by patient

age, sex, and pregnancy status, and you can

download the recommendations as well as receive

automatic updates to your PDA.

Chemoprevention of Breast Cancer

20
21

Screening for Breast Cancer (2009)

Summary of 2009 Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends biennial screening

mammography for women aged 50 to 74 years.

Grade: B Recommendation.

The decision to start regular, biennial screening

mammography before the age of 50 years should

be an individual one and take patient context into

account, including the patient’s values regarding

specific benefits and harms. Grade: C

Recommendation.

The USPSTF concludes that the current

evidence is insufficient to assess the additional

benefits and harms of screening mammography in

women 75 years or older. Grade: I Statement.

The USPSTF recommends against teaching

breast self-examination (BSE). Grade: D

Recommendation.

The USPSTF concludes that the current

evidence is insufficient to assess the additional

benefits and harms of clinical breast examination

(CBE) beyond screening mammography in

women 40 years or older. Grade: I Statement.
Clinical Considerations

n This recommendation statement applies to women

40 years or older who are not at increased risk for

breast cancer by virtue of a known underlying

genetic mutation or a history of chest radiation.

n Increasing age is the most important risk factor for

breast cancer for most women. Women without

known deleterious genetic mutations (such as

BRCA1 or BRCA2) may still have other

demographic, physical, or historical risk factors for

breast cancer, but none conveys a clinically

important absolute increased risk for cancer.

n In recent decades, the early detection of breast

cancer has been accomplished by physical

examination by a clinician (CBE), by a woman

herself (BSE), or by mammography. Standardization

of mammography practices enacted by the

Mammography Quality Standards Act have led to

improved mammography quality. Clinicians should

refer patients to Mammography Quality Standards

Act-certified facilities, a list of which is available at

Screening for Breast Cancer (2009)

22

The USPSTF concludes that the current

evidence is insufficient to assess the additional

benefits and harms of either digital mammography

or magnetic resonance imaging (MRI) instead of

film mammography as screening modalities for

breast cancer. Grade: I Statement.
Screening for Breast Cancer (2009)

23

http://www.fda.gov/cdrh/mammography/

certified.html.

n In trials that demonstrated the effectiveness of

mammography in decreasing breast cancer

mortality, screening was performed every 12 to 33

months. The evidence reviewed by the USPSTF

indicates that a large proportion of the benefit of

screening mammography is maintained by biennial

screening, and changing from annual to biennial

screening is likely to reduce the harms of

mammography screening by nearly half. At the

same time, benefit may be reduced when extending

the interval beyond 24 months; therefore the

USPSTF recommends biennial screening.

n Effective treatments, including radiation,

chemotherapy (including hormonal treatment), and

surgery, are available for invasive carcinoma.

Although the standard treatments women receive

for ductal carcinoma in situ (DCIS) include surgical

approaches as well as radiation and hormonal

therapy, considerable debate exists about the

optimal treatment strategy for this condition.

Clinical Breast Examination

Potential Preventable Burden. The evidence for CBE,

although indirect, suggests that CBE may detect a

substantial proportion of cases of cancer if it is the only

screening test available. In parts of the world where

mammography is infeasible or unavailable (such as

India), CBE is being investigated in this way.
Potential Harms. The potential harms of CBE are

thought to be small but include false-positive test

results, which lead to anxiety and breast cancer worry,

as well as repeated visits and unwarranted imaging and

biopsies.

Costs. The principal cost of CBE is the opportunity

cost incurred by clinicians in the patient encounter.

Current Practice. Surveys suggest that the CBE

technique used in the United States currently lacks a

standard approach and reporting standards. Clinicians

who are committed to spending the time on CBE

would benefit their patients by considering the

evidence in favor of a structured, standardized

examination.

Digital Mammography

Potential Preventable Burden. Digital mammography

detects some cases of cancer not identified by film

mammography; film mammography detects some cases

of cancer not identified by digital mammography.

Overall detection is similar for many women. For

women who are younger than 50 years or have dense

breast tissue, overall detection is somewhat higher with

digital mammography. It is not clear whether this

additional detection would lead to reduced mortality

from breast cancer.

Potential Harms. The possibility of false-positive test

results is similar for film and digital mammography. It

is uncertain whether overdiagnosis occurs more with

digital mammography than with film mammography.

24

Screening for Breast Cancer (2009)
Costs. Digital mammography is more expensive than

film mammography.

Current Practice. Some clinical practices are now

switching their mammography equipment from film to

digital. This may curtail the availability of film

mammography in some areas.

Magnetic Resonance Imaging

Potential Preventable Burden. Studies of the use of

contrast-enhanced MRI for breast cancer screening

have been conducted only in very high-risk

populations. In these studies, MRI detected more cases

of cancer than did mammography. It is unknown

whether detecting these additional cases of cancer

would lead to reduced breast cancer mortality.

Potential Harms. Contrast-enhanced MRI requires

the injection of contrast material. Studies of MRI

screening have shown that MRI yields many more

false-positive results than does mammography.

Magnetic resonance imaging has the potential to be

associated with a greater degree of overdiagnosis than

mammography.

Costs. Magnetic resonance imaging is much more

expensive than either film or digital mammography.

Current Practice. Magnetic resonance imaging is not

currently used for screening women at average risk for

breast cancer.

25

Screening for Breast Cancer (2009)
Screening for Breast Cancer (2009)

26

Screening Mammography in Women 75

Years or Older

Potential Preventable Burden. No women 75 years or

older have been included in the multiple randomized

clinical trials of breast cancer screening. Breast cancer is

a leading cause of death in older women, which might

suggest that the benefits of screening could be

important at this age. However, 3 facts suggest that

benefits from screening would probably be smaller for

this age group than for women aged 60 to 69 years and

probably decrease with increasing age: 1) the benefits

of screening occur only several years after the actual

screening test, whereas the percentage of women who

survive long enough to benefit decreases with age; 2) a

higher percentage of the type of breast cancer detected

in this age group is the more easily treated estrogen

receptor-positive type; and 3) women of this age are at

much greater risk for dying of other conditions that

would not be affected by breast cancer screening.

Potential Harms. Screening detects not only cancer

that could lead to a woman’s death but also cancer that

will not shorten a woman’s life. Women cannot benefit

from—but can be harmed by—the discovery and

treatment of this second type of cancer, which includes

both cancer that might some day become clinically

apparent and cancer that never will. Detection of

cancer that would never have become clinically

apparent is called overdiagnosis, and it is usually

followed by overtreatment. Because of a shortened life
Screening for Breast Cancer (2009)

27

span among women 75 years or older, the probability

of overdiagnosis and unnecessary earlier treatment

increases dramatically after about age 70 or 75 years.

Overdiagnosis and unnecessary earlier treatment are

important potential harms from screening women in

this age group.

Current Practice. Studies show that many women 75

years or older are currently being screened.

This USPSTF recommendation was first published in:

Ann Intern Med 2009; 151:716-726.
Screening for Breast Cancer (2002)

NOTE: The Department of Health and Human

Services, in implementing the Affordable Care Act, uses

the 2002 recommendation on Breast Cancer Screening,

below. The USPSTF provides this information to assist

primary care clinicians as they discuss insurance and

coverage issues with their patients.

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening mammography,

with or without clinical breast examination (CBE),

every 1-2 years for women aged 40 and older.

Grade: B Recommendation.

The USPSTF concludes that the evidence is

insufficient to recommend for or against routine

CBE alone to screen for breast cancer. Grade:

I Statement.

The USPSTF concludes that the evidence is

insufficient to recommend for or against teaching

or performing routine breast self-examination

(BSE). Grade: I Statement.

Clinical Considerations

n The precise age at which the benefits from screening

mammography justify the potential harms is a

subjective judgment and should take into account

patient preferences. Clinicians should inform

women about the potential benefits (reduced chance

of dying from breast cancer), potential harms (e.g.,

false-positive results, unnecessary biopsies), and

28
limitations of the test that apply to women their

age. Clinicians should tell women that the balance

of benefits and potential harms of mammography

improves with increasing age for women between

the ages of 40 and 70.

n Women who are at increased risk for breast cancer

(e.g., those with a family history of breast cancer in

a mother or sister, a previous breast biopsy revealing

atypical hyperplasia, or first childbirth after age 30)

are more likely to benefit from regular

mammography than women at lower risk. The

recommendation for women to begin routine

screening in their 40s is strengthened by a family

history of breast cancer having been diagnosed

before menopause.

n The USPSTF did not examine whether women

should be screened for genetic mutations (e.g.,

BRCA1 and BRCA2) that increase the risk for

developing breast cancer, or whether women with

genetic mutations might benefit from earlier or

more frequent screening for breast cancer.

n In the trials that demonstrated the effectiveness of

mammography in lowering breast cancer mortality,

screening was performed every 12-33 months. For

women aged 50 and older, there is little evidence to

suggest that annual mammography is more effective

than mammography done every other year. For

women aged 40-49, available trials also have not

reported a clear advantage of annual mammography

over biennial mammography. Nevertheless, some

29

Screening for Breast Cancer (2002)
experts recommend annual mammography based

on the lower sensitivity of the test and on evidence

that tumors grow more rapidly in this age group.

n The precise age at which to discontinue screening

mammography is uncertain. Only 2 randomized

controlled trials enrolled women older than 69 and

no trials enrolled women older than 74. Older

women face a higher probability of developing and

dying from breast cancer but also have a greater

chance of dying from other causes. Women with

comorbid conditions that limit their life expectancy

are unlikely to benefit from screening.

n Clinicians should refer patients to mammography

screening centers with proper accreditation and

quality assurance standards to ensure accurate

imaging and radiographic interpretation. Clinicians

should adopt office systems to ensure timely and

adequate follow-up of abnormal results. A listing of

accredited facilities is available at

http://www.fda.gov/cdrh/mammography/

certified.html.

n Clinicians who advise women to perform BSE or

who perform routine CBE to screen for breast

cancer should understand that there is currently

insufficient evidence to determine whether these

practices affect breast cancer mortality, and that

they are likely to increase the incidence of clinical

assessments and biopsies.

This USPSTF recommendation was first published in:

Ann Intern Med. 2002; 137 (Part 1):344-346.

30

Screening for Breast Cancer (2002)
31

Screening for Cervical Cancer

NOTE: An update to this recommendation is in

progress. Please visit our Web site at

http://www.USPreventiveServicesTaskForce.org or the

USPSTF’s Electronic Preventive Services Selector

(ePSS) at http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) strongly recommends screening for

cervical cancer in women who have been sexually

active and have a cervix. Grade: A Recommendation.

The USPSTF recommends against routinely

screening women older than age 65 for cervical

cancer if they have had adequate recent screening

with normal Pap smears and are not otherwise at

high risk for cervical cancer (go to Clinical

Considerations). Grade: D Recommendation.

The USPSTF recommends against routine Pap

smear screening in women who have had a total

hysterectomy for benign disease. Grade: D

Recommendation.

The USPSTF concludes that the evidence is

insufficient to recommend for or against the

routine use of new technologies to screen for

cervical cancer. Grade: I Statement.

The USPSTF concludes that the evidence is

insufficient to recommend for or against the

routine use of human papillomavirus (HPV)

testing as a primary screening test for cervical

cancer. Grade: I Statement.
Clinical Considerations

n The goal of cytologic screening is to sample the

transformation zone, the area where physiologic

transformation from columnar endocervical

epithelium to squamous (ectocervical) epithelium

takes place and where dysplasia and cancer arise. A

meta-analysis of randomized trials supports the

combined use of an extended tip spatula to sample

the ectocervix and a cytobrush to sample the

endocervix.

n The optimal age to begin screening is unknown.

Data on natural history of HPV infection and the

incidence of high-grade lesions and cervical cancer

suggest that screening can safely be delayed until 3

years after onset of sexual activity or until age 21,

whichever comes first. Although there is little value

in screening women who have never been sexually

active, many U.S. organizations recommend routine

screening by age 18 or 21 for all women, based on

the generally high prevalence of sexual activity by

that age in the U.S. and concerns that clinicians

may not always obtain accurate sexual histories.

n Discontinuation of cervical cancer screening in older

women is appropriate, provided women have had

adequate recent screening with normal Pap results.

The optimal age to discontinue screening is not clear,

but risk of cervical cancer and yield of screening

decline steadily through middle age. The USPSTF

found evidence that yield of screening was low in

previously screened women after age 65. New

32

Screening for Cervical Cancer
American Cancer Society (ACS) recommendations

suggest stopping cervical cancer screening at age 70.

Screening is recommended in older women who

have not been previously screened, when

information about previous screening is unavailable,

or when screening is unlikely to have occurred in

the past (e.g., among women from countries

without screening programs). Evidence is limited to

define “adequate recent screening.” The ACS

guidelines recommend that older women who have

had three or more documented, consecutive,

technically satisfactory normal/negative cervical

cytology tests, and who have had no

abnormal/positive cytology tests within the last 10

years, can safely stop screening.

n The USPSTF found no direct evidence that annual

screening achieves better outcomes than screening

every 3 years. Modeling studies suggest little added

benefit of more frequent screening for most women.

The majority of cervical cancers in the United

States occur in women who have never been

screened or who have not been screened within the

past 5 years; additional cases occur in women who

do not receive appropriate follow-up after an

abnormal Pap smear. Because sensitivity of a single

Pap test for high-grade lesions may only be 60-

80%, however, most organizations in the United

States recommend that annual Pap smears be

performed until a specified number (usually two or

three) are cytologically normal before lengthening

the screening interval. The ACS guidelines suggest

33

Screening for Cervical Cancer
waiting until age 30 before lengthening the

screening interval; the American College of

Obstetricians and Gynecologists (ACOG) identifies

additional risk factors that might justify annual

screening, including a history of cervical neoplasia,

infection with HPV or other sexually transmitted

diseases (STDs), or high-risk sexual behavior, but

data are limited to determine the benefits of these

strategies.

n Discontinuation of cytological screening after total

hysterectomy for benign disease (e.g., no evidence

of cervical neoplasia or cancer) is appropriate given

the low yield of screening and the potential harms

from false-positive results in this population.

Clinicians should confirm that a total hysterectomy

was performed (through surgical records or

inspecting for absence of a cervix); screening may be

appropriate when the indications for hysterectomy

are uncertain. ACS and ACOG recommend

continuing cytologic screening after hysterectomy

for women with a history of invasive cervical cancer

or DES exposure due to increased risk for vaginal

neoplasms, but data on the yield of such screening

are sparse.

n A majority of cases of invasive cervical cancer occur

in women who are not adequately screened.

Clinicians, hospitals, and health plans should

develop systems to identify and screen the subgroup

of women who have had no screening or who have

had inadequate past screening.

34

Screening for Cervical Cancer
n Newer Food and Drug Administration (FDA)-

approved technologies, such as the liquid-based

cytology (e.g., ThinPrep®), may have improved

sensitivity over conventional Pap smear screening,

but at a considerably higher cost and possibly with

lower specificity. Even if sensitivity is improved,

modeling studies suggest these methods are not

likely to be cost-effective unless used with screening

intervals of 3 years or longer. Liquid-based cytology

permits testing of specimens for HPV, which may

be useful in guiding management of women whose

Pap smear reveals atypical squamous cells. HPV

DNA testing for primary cervical cancer screening

has not been approved by the FDA and its role in

screening remains uncertain.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. January 2003. http://www.USPreventiveServicesTask

Force.org.

35

Screening for Cervical Cancer
Screening for Colorectal Cancer

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for colorectal

cancer using fecal occult blood testing,

sigmoidoscopy, or colonoscopy in adults, beginning

at age 50 years and continuing until age 75 years.

The risks and benefits of these screening methods

may vary. Grade: A Recommendation.

The USPSTF recommends against routine

screening for colorectal cancer in adults 76 to 85

years of age. There may be considerations that

support colorectal cancer screening in an individual

patient. Grade: C Recommendation.

The USPSTF recommends against screening for

colorectal cancer in adults older than age 85 years.

Grade: D Recommendation.

The USPSTF concludes that the evidence is

insufficient to assess the benefits and harms of

computed tomographic colonography and fecal

DNA testing as screening modalities of colorectal

cancer. Grade: I Statement.

Clinical Considerations

n These recommendations apply to adults 50 years of

age and older, excluding those with specific

inherited syndromes (the Lynch syndrome of

familial adenomatous polyposis) and those with

inflammatory bowel disease. The recommendations

do apply to those with first-degree relatives who

36
have had colorectal adenomas or cancer, although

for those with first-degree relatives who developed

cancer at a younger age or those with multiple

affected first-degree relatives, an earlier start to

screening may be reasonable. Data suggest that

colorectal cancer has a higher mortality rate in

African Americans. The reasons for this differential

are not well known, and the recommendations are

intended to apply to all ethnic and racial groups.

When the screening test results in the diagnosis of

clinically significant colorectal adenomas or cancer,

the patient will be followed by a surveillance

regimen and recommendations for screening are no

longer applicable. The USPSTF did not address

evidence for the effectiveness of any particular

surveillance regimen after diagnosis and/or removal

of adenomatous polyps.

n The relative sensitivity and specificity of the

different colorectal screening tests with adequate

data to assess cancer detection—colonoscopy,

flexible sigmoidoscopy, and fecal tests—can be

depicted as follows:

– Sensitivity: Hemoccult II < fecal

immunochemical tests ≤ Hemoccult SENSA ≈

flexible sigmoidoscopy < colonoscopy

– Specificity: Hemoccult SENSA < fecal

immunochemical tests ≈ Hemoccult II <

flexible sigmoidoscopy = colonoscopy

37

Screening for Colorectal Cancer
For the operator-dependent tests—flexible

sigmoidoscopy, CT colonography, and

colonoscopy—better operator training and more

experience have a high likelihood of improving

sensitivity. Approaches related to certification, such

as quality standards and possibly minimum volume

requirements, could be used to achieve the goal of

improving operator performance and therefore test

sensitivity. Assurance of performance of high-quality

endoscopy should be part of all screening programs.

Because several screening strategies have similar

efficacy, efforts to reduce colon cancer deaths

should focus on implementation of strategies that

maximize the number of individuals who get

screening of some type. The different options for

colorectal cancer screening tests are variably

acceptable to patients; eliciting patient preferences is

one step in improving adherence. Ideally, shared

decision making between clinicians and patients

would incorporate information on local test

availability and quality as well as patient preference.

n Screening for colorectal cancer reduces mortality

through detection and treatment of early-stage

cancer and detection and removal of adenomatous

polyps. The degree to which each of these

mechanisms contributes to a reduction in mortality

is unknown, although it is likely that the largest

reduction in colorectal cancer mortality during the

10 years after initial screening comes from the

detection and removal of early-stage cancer.

Colonoscopy is a necessary step in any screening

38

Screening for Colorectal Cancer
program that reduces mortality from colorectal

cancer. This reduction in mortality does come at the

expense of significant morbidity associated with

colonoscopy. Evidence does not currently allow a

differential estimate of colonoscopy-related

morbidity for different age groups or for

examinations done with or without biopsy.

In this context, the best measure for the morbidity

that results from any screening program for

colorectal cancer is the number of colonoscopies

required to achieve a reduction in mortality.

Although improvements in mortality will generally

be associated with increasing morbidity that results

from the screening and surveillance program, the

goal of a screening program should be to maximize

the number of life-years gained while minimizing

the harms.

In a report prepared for the USPSTF by 2 groups in

the Cancer Intervention and Surveillance Modeling

Network (CISNET), investigators conducted

microsimulation analyses that applied programs of

screening to standard populations of adults in the

United States. These analyses permitted a

comparison of expected outcomes among testing

strategies involving the fecal tests, flexible

sigmoidoscopy, or colonoscopy (as noted below). In

the models, the predicted total number of

colonoscopies included those resulting from

surveillance after detection of colorectal neoplasia.

The models assumed lifetime monitoring by

colonoscopy every 3 to 5 years depending on the

39

Screening for Colorectal Cancer
number and size of the adenomas detected. It is not

the intent of the USPSTF to endorse this particular

approach to surveillance, but standardizing the

approach to surveillance is necessary to compare

screening strategies in the models.

For all screening modalities, starting screening at

age 50 resulted in a balance between life-years

gained and colonoscopy risks that was more

favorable than commencing screening earlier.

Despite the increasing incidence of colorectal

adenomas with age, for individuals previously

screened the gain in life-years associated with

extending screening from age 75 years to 85 years

was small in comparison to the risks of screening

people in this decade. For adults who have not

previously been screened, decisions about first-time

screening in this age group should be made in the

context of the individual’s health status and

competing risks, given that the benefit of screening

is not seen in trials until at least 7 years later. For

persons older than 85 years, competing causes of

mortality preclude a mortality benefit that

outweighs the harms.

This USPSTF recommendation was first published in:

Ann Intern Med. 2008; 149(9):627-638.

40

Screening for Colorectal Cancer
Lung Cancer Screening

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend for or against screening

asymptomatic persons for lung cancer with either

low dose computerized tomography (LDCT), chest

x-ray (CXR), sputum cytology, or a combination of

these tests. Grade: I Statement.

Clinical Considerations

n The benefit of screening for lung cancer has not

been established in any group, including

asymptomatic high-risk populations such as older

smokers. The balance of harms and benefits

becomes increasingly unfavorable for persons at

lower risk, such as nonsmokers.

n The sensitivity of LDCT for detecting lung cancer

is 4 times greater than the sensitivity of CXR.

However, LDCT is also associated with a greater

number of false-positive results, more radiation

exposure, and increased costs compared with CXR.

n Because of the high rate of false-positive results,

many patients will undergo invasive diagnostic

procedures as a result of lung cancer screening.

Although the morbidity and mortality rates from

these procedures in asymptomatic individuals are

41
not available, mortality rates due to complications

from surgical interventions in symptomatic patients

reportedly range from 1.3% to 11.6%; morbidity

rates range from 8.8% to 44%, with higher rates

associated with larger resections.

n Other potential harms of screening are potential

anxiety and concern as a result of false-positive tests,

as well as possible false reassurance because of falsenegative results. However, these harms have not

been adequately studied.

This USPSTF recommendation was first published in:

Ann Intern Med. 2004; 140:738-739.

42

Lung Cancer Screening
Screening for Oral Cancer

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend for or against routinely

screening adults for oral cancer. Grade: I Statement.

Clinical Considerations

n Direct inspection and palpation of the oral cavity is

the most commonly recommended method of

screening for oral cancer, although there are little

data on the sensitivity and specificity of this

method. Screening techniques other than inspection

and palpation are being evaluated but are still

experimental.

n Tobacco use in all forms is the biggest risk factor for

oral cancer. Alcohol abuse combined with tobacco

use increases risk.

n Clinicians should be alert to the possibility of oral

cancer when treating patients who use tobacco or

alcohol.

43
n Patients should be encouraged to not use tobacco

and to limit alcohol use in order to decrease their

risk for oral cancer as well as heart disease, stroke,

lung cancer, and cirrhosis.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. February 2004. http://www.USPreventiveServicesTask

Force.org.

44

Screening for Oral Cancer
Screening for Ovarian Cancer

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine screening

for ovarian cancer. Grade: D Recommendation.

Clinical Considerations

n There is no existing evidence that any screening

test, including CA-125, ultrasound, or pelvic

examination, reduces mortality from ovarian cancer.

Furthermore, existing evidence that screening can

detect early-stage ovarian cancer is insufficient to

indicate that this earlier diagnosis will reduce

mortality.

n Because there is a low incidence of ovarian cancer in

the general population (age-adjusted incidence of

17 per 100,000 women), screening for ovarian

cancer is likely to have a relatively low yield. The

great majority of women with a positive screening

test will not have ovarian cancer (i.e., they will have

a false-positive result). In women at average risk, the

positive predictive value of an abnormal screening

test is, at best, approximately 2% (i.e., 98% of

45
women with positive test results will not have

ovarian cancer).

n The positive predictive value of an initially positive

screening test would be more favorable for women

at higher risk. For example, the lifetime probability

of ovarian cancer increases from about 1.6% in a

35-year-old woman without a family history of

ovarian cancer to about 5% if she has 1 relative and

7% if she has 2 relatives with ovarian cancer. If

ongoing clinical trials show that screening has a

beneficial effect on mortality rates, then women at

higher risk are likely to experience the greatest

benefit.

This USPSTF recommendation was first published in:

Ann Fam Med. 2004; 2:260-262.

46

Screening for Ovarian Cancer
Screening for Pancreatic Cancer

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine screening

for pancreatic cancer in asymptomatic adults using

abdominal palpation, ultrasonography, or serologic

markers. Grade: D Recommendation.

Clinical Considerations

n Due to the poor prognosis of those diagnosed with

pancreatic cancer, there is an interest in primary

prevention. The evidence for diet-based prevention

of pancreatic cancer is limited and conflicting.

Some experts recommend lifestyle changes that may

help to prevent pancreatic cancer, such as stopping

the use of tobacco products, moderating alcohol

intake, and eating a balanced diet with sufficient

fruit and vegetables.

n Persons with hereditary pancreatitis may have a

higher lifetime risk for developing pancreatic cancer.

However, the USPSTF did not review the

effectiveness of screening these patients.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. February 2004. http://www.USPreventiveServicesTask

Force.org.

47
Screening for Prostate Cancer

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) concludes that the current evidence is

insufficient to assess the balance of benefits and

harms of prostate cancer screening in men younger

than age 75 years. Grade: I Statement.

The USPSTF recommends against screening for

prostate cancer in men age 75 years or older.

Grade: D Recommendation.

Clinical Considerations

n This recommendation applies to men in the general

U.S. population.

n Older men, African-American men, and men with a

family history of prostate cancer are at increased risk

for diagnosis of and death from prostate cancer.

Unfortunately, the previously described gaps in the

evidence regarding potential benefits of screening

also apply to these men.

n The PSA test is more sensitive than the digital rectal

examination for detecting prostate cancer. The

conventional PSA screening cut-point of 4.0 μg/L

detects many cases of prostate cancer; however,

some early cases will be missed by this cut-point.

Using a lower cut-point to define an abnormal PSA

level detects more cases of cancer.

The proportion of cancer cases detected by lower

cutpoints that would ever become clinically

48
apparent is unknown; lower cut-points would label

many more men as potentially having cancer. For

example, lowering the PSA cut-point to 2.5 μg/L

would more than double the number of U.S. men

between 40 and 69 years of age with abnormal

results.

Variations of PSA screening, including the use of

age-adjusted PSA cut-points, free PSA, PSA density,

PSA velocity, PSA slope, and PSA doubling time,

have been proposed to improve detection of

“clinically important” prostate cancer cases.

However, no evidence suggests that any of these

testing strategies improves health outcomes.

n Given the uncertainties and controversy

surrounding prostate cancer screening in men

younger than age 75 years, a clinician should not

order the PSA test without first discussing with the

patient the potential but uncertain benefits and the

known harms of prostate cancer screening and

treatment. Men should be informed of the gaps in

the evidence and should be assisted in considering

their personal preferences before deciding whether

to be tested.

n Because of the uncertainty about the benefits of

treating prostate cancer detected by screening men

younger than age 75 years, there is no consensus

regarding optimal treatment. Current management

strategies for localized prostate cancer include

watchful waiting (observation with palliative

treatment for symptoms only), active surveillance

49

Screening for Prostate Cancer
(periodic biochemical monitoring with conversion

to curative treatment for signs of disease

progression), radical prostatectomy, external-beam

radiation therapy, and brachytherapy (or radioactive

seed implantation therapy).

If treatment for prostate cancer detected by

screening improves health outcomes, the population

most likely to benefit from screening will be men

age 50 to 74 years. Even if prostate cancer screening

is determined to be effective, the length of time

required to experience a mortality benefit is greater

than 10 years. Because a 75-year-old man has an

average life expectancy of about 10 years, very few

men age 75 years or older would experience a

mortality benefit. Similarly, men younger than age

75 years who have chronic medical problems and a

life expectancy of fewer than 10 years are also

unlikely to benefit from screening and treatment.

n The yield of screening in terms of cancer cases

detected declines rapidly with repeated annual

testing. If screening were to reduce deaths, PSA

screening as infrequently as every 4 years could yield

as much of a benefit as annual screening.

n Shared decision-making resources specific to

prostate cancer screening for clinicians and patients

are available from the Centers of Disease Control

and Prevention (www.cdc.gov/cancer/prostate/

publications/).

This USPSTF recommendation was first published in:

Ann Intern Med 2008; 149:185-191.

50

Screening for Prostate Cancer
Counseling to Prevent Skin Cancer

NOTE: The USPSTF was updating its

recommendation on this topic during publication

of The Guide to Clinical Preventive Services 2010-

2011. For the most recent recommendation, please

visit the USPSTF Web site at:

http://www.USPreventiveServicesTaskForce.org or

the USPSTF’s Electronic Preventive Services

Selector (ePSS) at http://epss.ahrq.gov. You can

search the ePSS for recommendations by patient

age, sex, and pregnancy status, and you can

download the recommendations as well as receive

automatic updates to your PDA.

51
Screening for Skin Cancer

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the current evidence is

insufficient to assess the balance of benefits and

harms of using whole-body skin examination by a

primary care clinician or patient skin selfexamination for the early detection of cutaneous

melanoma, basal cell cancer, or squamous cell skin

cancer in the adult general population. Grade: I

Statement.

Clinical Considerations

n This recommendation applies to the adult general

population without a history of premalignant or

malignant lesions. The USPSTF did not examine

the outcomes related to surveillance of patients at

extremely high risk, such as those with familial

syndromes (for example, the familial atypical mole

and melanoma syndrome).

n Clinicians should remain alert for skin lesions with

malignant features noted in the context of physical

examinations performed for other purposes.

Asymmetry, border irregularity, color variability,

diameter greater than 6 mm (ABCD criteria), or

rapidly changing lesions are features associated with

an increased risk for cancer. Biopsy of suspicious

lesions is warranted.

52
53

Screening for Skin Cancer

n Clinicians should be aware that fair-skinned men

and women older than 65 years, patients with

atypical moles, and those with more than 50 moles

constitute known groups at substantially increased

risk for melanoma. Other risk factors for skin

cancer include family history and a considerable

past history of sun exposure and sunburns. Benefits

from screening are uncertain, even in high-risk

patients.

This USPSTF recommendation was first published in:

Ann Intern Med. 2009; 150:188-193.
Screening for Testicular Cancer

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine screening

for testicular cancer in asymptomatic adolescent

and adult males. Grade: D Recommendation.

Clinical Considerations

n The low incidence of testicular cancer and favorable

outcomes in the absence of screening make it

unlikely that clinical testicular examinations would

provide important health benefits. Clinical

examination by a physician and self-examination are

the potential screening options for testicular cancer.

However, little evidence is available to assess the

accuracy, yield, or benefits of screening for testicular

cancer.

n Although currently most testicular cancers are

discovered by patients themselves or their partners,

either unintentionally or by self-examination, there

is no evidence that teaching young men how to

examine themselves for testicular cancer would

54
improve health outcomes, even among men at high

risk, including men with a history of undescended

testes or testicular atrophy.

n Clinicians should be aware of testicular cancer as a

possible diagnosis when young men present to them

with suggestive signs and symptoms. There is some

evidence that patients who present initially with

symptoms of testicular cancer are frequently

diagnosed as having epididymitis, testicular trauma,

hydrocele, or other benign disorders. Efforts to

promote prompt assessment and better evaluation

of testicular problems may be more effective than

widespread screening as a means of promoting early

detection.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. February 2004. http://www.USPreventiveServicesTask

Force.org.

55

Screening for Testicular Cancer
NOTE: The USPSTF was updating its

recommendation on this topic during

publication of The Guide to Clinical Preventive

Services 2010-2011. For the most recent

recommendation, please visit our Web site at:

http://www.USPreventiveServicesTaskForce.org

or the USPSTF’s Electronic Preventive Services

Selector (ePSS) at http://epss.ahrq.gov. You can

search the ePSS for recommendations by patient

age, sex, and pregnancy status, and you can

download the recommendations as well as receive

automatic updates to your PDA.

56

Routine Vitamin Supplementation to

Prevent Cancer and Cardiovascular

Disease
57

Heart, Vascular, and

Respiratory Diseases

Screening for Abdominal Aortic

Aneurysm

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends one-time screening for

abdominal aortic aneurysm (AAA) by

ultrasonography in men aged 65 to 75 who have

ever smoked. Grade: B Recommendation.

The USPSTF makes no recommendation for or

against screening for AAA in men aged 65 to 75

who have never smoked. Grade: C

Recommendation.

The USPSTF recommends against routine

screening for AAA in women. Grade: D

Recommendation.

Clinical Considerations

n The major risk factors for abdominal aortic

aneurysm (AAA) include age (being 65 or older),

male sex, and a history of ever smoking (at least 100

cigarettes in a person’s lifetime). A first-degree

family history of AAA requiring surgical repair also

elevates a man’s risk for AAA; this may also be true

for women but the evidence is less certain. There is
only a modest association between risk factors for

atherosclerotic disease and AAA.

n Screening for AAA would most benefit those who

have a reasonably high probability of having an

AAA large enough, or that will become large

enough, to benefit from surgery. In general, adults

younger than age 65 and adults of any age who

have never smoked are at low risk for AAA and are

not likely to benefit from screening. Among men

aged 65 to 74, an estimated 500 who have ever

smoked—or 1,783 who have never smoked—would

need to be screened to prevent 1 AAA-related death

in the next 5 years. As always, clinicians must

individualize recommendations depending on a

patient’s risk and likelihood of benefit. For example,

some clinicians may choose to discuss screening

with male nonsmokers nearing age 65 who have a

strong first-degree family history of AAA that

required surgery.

n The potential benefit of screening for AAA among

women aged 65 to 75 is low because of the small

number of AAA-related deaths in this population.

The majority of deaths from AAA rupture occur in

women aged 80 or older. Because there are many

competing health risks at this age, any benefit of

screening for AAA would be minimal.

Individualization of care, however, is still required.

For example, a clinician may choose to discuss

screening in the unusual circumstance in which a

healthy female smoker in her early 70s has a firstdegree family history for AAA that required surgery.

58

Screening for Abdominal Aortic Aneurysm
n Operative mortality for open surgical repair of an

AAA is 4 to 5 percent, and nearly one-third of

patients undergoing this surgery have other

important complications (e.g., cardiac and

pulmonary). Additionally, men having this surgery

are at increased risk for impotence.

n Endovascular repair of AAAs (EVAR) is currently

being used as an alternative to open surgical repair.

Although recent studies have shown a short-term

mortality and morbidity benefit of EVAR compared

with open surgical repair, the long-term

effectiveness of EVAR to reduce AAA rupture and

mortality is unknown. The long-term harms of

EVAR include late conversion to open repair and

aneurysmal rupture. EVAR performed with oldergeneration devices is reported to have an annual rate

of rupture of 1 percent and conversion to open

surgical repair of 2 percent. The conversion to open

surgical repair is associated with a peri-operative

mortality of about 24 percent. The long-term harms

of newer generation EVAR devices are yet to be

reported.

n For most men, 75 years may be considered an

upper age limit for screening. Patients cannot

benefit from screening and subsequent surgery

unless they have a reasonable life expectancy. The

increased presence of comorbidities for people aged

75 and older decreases the likelihood that they will

benefit from screening.

59

Screening for Abdominal Aortic Aneurysm
n Ultrasonography has a sensitivity of 95 percent and

specificity of nearly 100 percent when performed in

a setting with adequate quality assurance. The

absence of quality assurance is likely to lower test

accuracy. Abdominal palpation has poor accuracy

and is not an adequate screening test.

n One-time screening to detect an AAA using

ultrasonography is sufficient. There is negligible

health benefit in re-screening those who have

normal aortic diameter on initial screening.

n Open surgical repair for an AAA of at least 5.5 cm

leads to an estimated 43-percent reduction in AAAspecific mortality in older men who undergo

screening. However, there is no current evidence

that screening reduces all-cause mortality in this

population.

n In men with intermediate-sized AAAs (4.0-5.4 cm),

periodic surveillance offers comparable mortality

benefit to routine elective surgery with the benefit

of fewer operations. Although there is no evidence

to support the effectiveness of any intervention in

those with small AAAs (3.0-3.9 cm), there are

expert opinion-based recommendations in favor of

periodic repeat ultrasonography for these patients.

This USPSTF recommendation was first published in:

Ann Intern Med. 2005; 142:198-202.

60

Screening for Abdominal Aortic Aneurysm
Aspirin for the Prevention of

Cardiovascular Disease

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends the use of aspirin for men

age 45 to 79 years when the potential benefit due

to a reduction in myocardial infarctions outweighs

the potential harm due to an increase in

gastrointestinal hemorrhage. Grade: A

Recommendation.

The USPSTF recommends the use of aspirin for

women age 55 to 79 years when the potential

benefit of a reduction in ischemic strokes

outweighs the potential harm due to an increase in

gastrointestinal hemorrhage. Grade: A

Recommendation.

The USPSTF concludes that the current

evidence is insufficient to assess the balance of

benefits and harms of aspirin for cardiovascular

disease prevention in men and women 80 years or

older. Grade: I Statement.

The USPSTF recommends against the use of

aspirin for stroke prevention in women younger

than 55 years and for myocardial infarction

prevention in men younger than 45 years. Grade:

D Recommendation.

61
Clinical Considerations

n These recommendations apply to adult men and

women without a history of coronary heart disease

or stroke.

n Men

The net benefit of aspirin depends on the initial

risk for coronary heart disease events and

gastrointestinal bleeding. Thus, decisions about

aspirin therapy should consider the overall risks for

coronary heart disease and gastrointestinal bleeding.

Risk assessment for coronary heart disease should

include ascertainment of risk factors: age, diabetes,

total cholesterol levels, high-density lipoprotein

cholesterol levels, blood pressure, and smoking.

Available tools provide estimations of coronary

heart disease risk (such as the calculator available at

http://hp2010.nhlbihin.net/atpiii.calculator.asp).

Figure 1 shows the estimated number of myocardial

infarctions prevented according to coronary heart

disease risk level for men age 45 to 79 years—the

age range with the potential for substantial net

benefit from the use of aspirin. It also shows that

the coronary heart disease risk level at which the

absolute number of myocardial infarctions

prevented by the use of aspirin is greater than the

absolute number of gastrointestinal bleeding

episodes and hemorrhagic strokes caused by aspirin

therapy increases with age. The estimates in Figure

2 were developed assuming that the men are not

currently taking nonsteroidal anti-inflammatory

62

Aspirin for Prevention of CVD
63

Aspirin for Prevention of CVD

Figure 1. Estimated myocardial infarctions (MIs) prevented

and estimated harms of using aspirin for 10 years in a

hypothetical cohort of 1000 men

As indicated, the estimated number of MIs prevented varies with 10-year

CHD risk. The estimated harms of using aspirin vary with age. Therefore,

both 10-year CHD risk and age must be considered when determining

whether the potential harms of aspirin use outweigh the potential benefit in

terms of MIs prevented. The boldfaced numbers indicate the combinations

of 10-year CHD risk and age for which the number of harms (GI bleeding

and hemorrhagic stroke) are greater than or approximately equal to the

number of MIs prevented.*

Variable Estimated MIs Prevented (per 1000 Men), n

Age 45–59 Age 60–69 Age 70–79

Years Years Years 10-year CHD risk

1% 3.2 3.2 3.2

2% 6.4 6.4 6.4

3% 9.6 9.6 9.6

4% 12.8 12.8 12.8

5% 16 16 16

6% 19.2 19.2 19.2

7% 22.4 22.4 22.4

8% 25.6 25.6 25.6

9% 28.8 28.8 28.8

10% 32 32 32

11% 35.2 35.2 35.2

12% 38.4 38.4 38.4

13% 41.6 41.6 41.6

14% 44.8 44.8 44.8

15% 48 48 48

16% 51.2 51.2 51.2

17% 54.4 54.4 54.4

18% 57.6 57.6 57.6

19% 60.8 60.8 60.8

20% 64 64 64

continued
Figure 1. Estimated myocardial infarctions (MIs) prevented

and estimated harms of using aspirin for 10 years in a

hypothetical cohort of 1000 men (continued)

Variable Estimated MIs Prevented (per 1000 Men), n

Age 45–59 Age 60–69 Age 70–79

Years Years Years

Estimated Harms, n

Type of event

GI bleeding 8 24 36

Hemorrhagic

stroke 111

* Calculations of estimated benefits and harms rely on assumptions

and are by nature somewhat imprecise. Estimates of benefits and

harms, especially at the borders of the boldfaced and non-boldfaced

areas, should be considered in the full context of clinical decision

making and used to stimulate shared decision making. The

calculations in the table are based on the following assumptions:

that there is a 32% risk reduction of MIs with regular aspirin use

and that gastrointestinal bleeding includes serious hemorrhage,

perforation, or other complications leading to hospitalization or

death. The harm of GI bleeding in the table assumes that the risk

for GI bleeding increases with age and that the men are not taking

nonsteroidal anti-inflammatory drugs, do not have upper GI pain,

or do not have a history of GI ulcer.

Estimates are based on age and 10-year CHD risk. CHD =

coronary heart disease; GI = gastrointestinal; MI = myocardial

infarction.

Aspirin for Prevention of CVD

64
Aspirin for Prevention of CVD

65

drugs (NSAIDs) and are without other conditions

that increase the risk for gastrointestinal bleeding

(see below). Furthermore, the decision about the

exact level of risk at which the potential benefits

outweigh potential harms is an individual one.

Some men may decide that avoiding a myocardial

infarction is of great value and that having a

gastrointestinal bleeding event is not a major

problem. This group would probably decide to take

aspirin at a lower coronary heart disease risk level

than men who are more afraid of gastrointestinal

bleeding. Men who have a high likelihood of

benefiting with little potential for harm should be

encouraged to consider aspirin. Conversely, aspirin

use should be discouraged among men who have

little potential of benefiting from the therapy or

have a high risk for gastrointestinal bleeding.

Shared decision making should be encouraged with

men for whom the potential benefits and risks for

serious bleeding are more closely balanced (Figure

2). This discussion should explore the potential

benefits and harms and patient preferences. As the

potential benefit increases above potential harms,

the recommendation to take aspirin should become

stronger.

Evidence on the benefits in men younger than 45

years is limited, and the potential benefit in this age

group is probably low because the risk for

myocardial infarction is very low.
n Women

The net benefit of aspirin depends on the initial

risks for stroke and gastrointestinal bleeding. Thus,

decisions about aspirin therapy should consider the

overall risk for stroke and gastrointestinal bleeding.

Risk factors for stroke include age, high blood

pressure, diabetes, smoking, a history of

cardiovascular disease, atrial fibrillation, and left

ventricular hypertrophy. Tools for estimation of

stroke risk are available (such as the calculator

available at http://www.westernstroke.org/

PersonalStrokeRisk1.xls).

66

Aspirin for Prevention of CVD

Figure 2. 10-year CHD risk levels at which the number of

cardiovascular disease events prevented is closely balanced to

the number of serious bleeding events

Shared decision making is strongly encouraged with persons whose

risk is close to (either above or below) these estimates of 10-year

risk levels. As the potential cardiovascular disease reduction benefit

increases above harms, the recommendation to take aspirin should

become stronger.

Men Women

Age 10-Year CHD Age 10-Year Stroke

Risk, % Risk, %

45–59 y ≥4 55–59 y ≥3

60–69 y ≥9 60–69 y ≥8

70–79 y ≥12 70–79 y ≥11

CHD = coronary heart disease.
Figure 3 shows the estimated number of strokes

prevented according to stroke risk level in women

age 55 to 79 years—the age range for which

evidence shows that there could be substantial

potential net benefit of aspirin use. It also shows

that the stroke risk level at which the absolute

number of strokes prevented is greater than the

absolute number of gastrointestinal bleeding events

caused increases with age. The estimates in Figure 3

were developed assuming that women are not

currently taking NSAIDs and are without other

conditions that increase the risk for gastrointestinal

bleeding. Furthermore, the decision about the exact

stroke risk level at which the potential benefits

outweigh harms is an individual one. Some women

may decide that avoiding a stroke is of great value

but experiencing a gastrointestinal bleeding event is

not a major problem. These women would

probably decide to take aspirin at a lower stroke risk

level than those who are more afraid of a bleeding

event. Women who have little potential of

benefiting from aspirin therapy or have a high risk

for gastrointestinal bleeding should be discouraged

from taking aspirin.

Shared decision making should be encouraged with

women for whom the potential benefits and risks

for serious bleeding are more closely balanced

(Figure 2). This discussion should explore potential

benefits and harms and patient preferences. As the

potential stroke reduction benefit increases above

the potential harms, the recommendation to take

aspirin should become stronger.

67

Aspirin for Prevention of CVD
Aspirin

Figure 3. Estimated number of strokes prevented and estimated

harms of using aspirin for 10 years in a hypothetical cohort of

1000 women on the basis of age and 10-year stroke risk.

As indicated, the estimated number of strokes avoided varies with

10-year stroke risk. The estimated harms of using aspirin vary with

age. Therefore, both 10-year stroke risk and age must be considered

when determining whether the potential harms of aspirin use

outweigh the potential benefit in terms of strokes prevented. The

boldfaced numbers indicate the combinations of 10-year stroke risk

and age for which the number of harms (GI bleeding) are greater

than the number of strokes prevented*

Variable Estimated Strokes Prevented (per 1000 Women), n

Age 55–59 Age 60–69 Age 70–79

Years Years Years 10-year stroke risk

1% 1.7 1.7 1.7

2% 3.4 3.4 3.4

3% 5.1 5.1 5.1

4% 6.8 6.8 6.8

5% 8.5 8.5 8.5

6% 10.2 10.2 10.2

7% 11.9 11.9 11.9

8% 13.6 13.6 13.6

9% 15.3 15.3 15.3

10% 17 17 17

11% 18.7 18.7 18.7

12% 20.4 20.4 20.4

13% 22.1 22.1 22.1

14% 23.8 23.8 23.8

15% 25.5 25.5 25.5

16% 27.2 27.2 27.2

17% 28.9 28.9 28.9

18% 30.6 30.6 30.6

19% 32.3 32.3 32.3

20% 34 34 34

continued

Aspirin for Prevention of CVD

68
Aspirin

Figure 3. Estimated number of strokes prevented and estimated

harms of using aspirin for 10 years in a hypothetical cohort of

1000 women on the basis of age and 10-year stroke risk.

(continued)

Variable Estimated Strokes Prevented (per 1000 Women), n

Age 55–59 Age 60–69 Age 70–79

Years Years Years

Estimated Harms, n

Type of event

GI bleeding 4 12 18

* Calculations of estimated benefits and harms rely on assumptions

and are by nature somewhat imprecise. Estimates of benefits and

harms, especially at the borders of the boldfaced and non-boldfaced

areas, should be considered in the full context of clinical decision

making and used to stimulate shared decision making. The

calculations in the table are based on the following assumptions:

that there is a 17% risk reduction of strokes with regular aspirin

use and that gastrointestinal bleeding includes serious hemorrhage,

perforation, or other complications leading to hospitalization or

death. The harm of GI bleeding in the table assumes that the risk

for GI bleeding increases with age and that the women are not

taking nonsteroidal anti-inflammatory drugs, do not have upper GI

pain, or do not have a history of GI ulcer. “Strokes prevented” is

the net reduction of strokes, which includes a decrease in ischemic

strokes and a small increase in hemorrhagic strokes.

Aspirin for Prevention of CVD

69
Aspirin

Evidence on benefits in women younger than 55

years is limited, and the potential benefit in this age

group is probably low because the risk for stroke is

very low.

n Evidence shows that the risk for gastrointestinal

bleeding with and without aspirin use increases with

age. For the purposes of making this

recommendation, the USPSTF considered age and

sex to be the most important risk factors for

gastrointestinal bleeding. Other risk factors for

bleeding include upper gastrointestinal tract pain,

gastrointestinal ulcers, and NSAID use.

Nonsteroidal anti-inflammatory drug therapy

combined with aspirin approximately quadruples

the risk for serious gastrointestinal bleeding

compared with the risk with aspirin alone. The rate

of serious bleeding in aspirin users is approximately

2 to 3 times greater in patients with a history of a

gastrointestinal ulcer. Men have twice the risk for

serious gastrointestinal bleeding than women. These

risk factors increase the risk for bleeding

substantially and should be considered in the overall

decision about the balance of benefits and harms of

aspirin therapy. Enteric-coated or buffered

preparations do not clearly reduce the adverse

gastrointestinal effects of aspirin. Uncontrolled

hypertension and concomitant use of anticoagulants

also increase the risk for serious bleeding.

Aspirin for Prevention of CVD

70
n The optimum dose of aspirin for preventing

cardiovascular disease events is not known. Primary

prevention trials have demonstrated benefits with

various regimens, including dosages of 75 and 100

mg/d and 100 and 325 mg every other day. A

dosage of approximately 75 mg/d seems as effective

as higher dosages. The risk for gastrointestinal

bleeding may increase with dose.

n Although the optimal timing and frequency of

discussions related to aspirin therapy are unknown,

a reasonable option might be every 5 years in

middle age and later and also whenever other

cardiovascular risk factors are detected.

n The incidence of myocardial infarction and stroke is

high in persons 80 years or older, and thus the

potential benefit of aspirin is large. The relationship

between increasing age and gastrointestinal bleeding

is also well established, and thus the potential harms

are also large. The net benefit of aspirin use in

persons older than 80 years is probably best in those

without risk factors for gastrointestinal bleeding

(other than older age) and in those who could

tolerate a gastrointestinal bleeding episode (for

example, those with normal hemoglobin levels,

good kidney function, and easy access to emergency

care). Clinicians should inform patients about the

adverse consequences of gastrointestinal bleeding

because they might be mitigated by a patient’s early

Aspirin for PArsepviernintion of CVD

71
Aspirin for Prevention of CVD

72

recognition of the signs and symptoms of bleeding

(dark stools, vomiting blood, bright red blood per

rectum, syncope, and lightheadedness). If clinicians

decide to prescribe aspirin in adults older than 80

years, they should do so only after a discussion with

the patient that includes the potential harms and

uncertain benefits.

This USPSTF recommendation was first published in:

Ann Intern Med. 2009; 150:396-404.
73

Screening for Carotid Artery Stenosis

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against screening for

asymptomatic carotid artery stenosis (CAS) in the

general adult population. Grade: D

Recommendation.

Clinical Considerations

n This recommendation applies to adults without

neurological signs or symptoms, including a history

of transient ischemic attacks or stroke. If otherwise

eligible, an individual who has a carotid-area

transient ischemic attack should be evaluated

promptly for consideration of carotid

endarterectomy.

n In a setting of excellent surgical care and low

complication rates, screening may benefit patients

who have a very high risk for stroke. It is not clear,

however, how to identify people whose risk for

stroke is high enough to justify screening, yet do

not also have a high risk for surgical complications.

The major risk factors for CAS include older age,

male sex, hypertension, smoking,

hypercholesterolemia, and heart disease.

n Available screening and confirmatory tests (duplex

ultrasonography, digital subtraction angiography,

and magnetic resonance angiography) all have

imperfect sensitivity and appreciable harms.
74

Screening for Carotid Artery Stenosis

Therefore, screening could lead to non-indicated

surgeries that result in serious harms, including

death, stroke, and myocardial infarction, in some

patients.

n In other recommendations, the USPSTF notes that

adults should be screened for hypertension,

hyperlipidemia, and smoking. In addition,

clinicians should discuss aspirin chemoprevention

for those who have an increased risk for

cardiovascular disease. The evidence and

recommendations for these conditions from the

USPSTF are available on the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org.

This USPSTF recommendation was first published in:

Ann Intern Med. 2007; 147:854-859.
Screening for Chronic Obstructive

Pulmonary Disease Using Spirometry

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against screening adults

for chronic obstructive pulmonary disease (COPD)

using spirometry. Grade: D Recommendation.

Clinical Considerations

n This recommendation applies to healthy adults who

do not recognize or report respiratory symptoms to

a clinician. It does not apply to individuals with a

family history of α1-antitrypsin deficiency. For

individuals who present to clinicians reporting

chronic cough, increased sputum production,

wheezing, or dyspnea, spirometry would be

indicated as a diagnostic test for COPD, asthma,

and other pulmonary diseases.

n Screening for COPD would theoretically benefit

adults with a high probability of severe airflow

obstruction who might benefit from inhaled

therapies. Risk factors for COPD include current or

past tobacco use, exposure to occupational and

environmental pollutants, and older age. However,

even in groups with the greatest prevalence of

airflow obstruction, hundreds of patients would

need to be screened with spirometry to defer 1

exacerbation. For example, under the best-case

75
assumptions about response to therapy, an

estimated 455 adults between 60 and 69 years of

age would need to be screened to defer 1

exacerbation.

n Spirometry can be performed in a primary care

physician’s office or in a pulmonary testing

laboratory. The USPSTF did not review evidence

comparing the accuracy of spirometry performed in

the primary care versus referral settings.

n Regardless of the presence or absence of airflow

obstruction, all current smokers should receive

smoking cessation counseling and be offered

pharmacologic therapies demonstrated to increase

cessation rates. All patients 50 years of age or older

should be offered influenza vaccine annually. All

patients 65 years of age or older should be offered

pneumococcal vaccine.

This USPSTF recommendation was first published in:

Ann Intern Med. 2008; 148:529-534.

Screening for COPD Using Spirometry

76
77

Screening for Coronary Heart Disease

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine screening

with resting electrocardiography (ECG), exercise

treadmill test (ETT), or electron-beam

computerized tomography (EBCT) scanning for

coronary calcium for either the presence of severe

coronary artery stenosis (CAS) or the prediction of

coronary heart disease (CHD) events in adults at

low risk for CHD events. Grade: D

Recommendation.

The USPSTF found insufficient evidence to

recommend for or against routine screening with

ECG, ETT, or EBCT scanning for coronary

calcium for either the presence of severe CAS or

the prediction of CHD events in adults at

increased risk for CHD events. Grade: I Statement.

Clinical Considerations

n Several factors are associated with a higher risk for

CHD events (the major ones are nonfatal

myocardial infarction and coronary death),

including older age, male gender, high blood
Screening for Coronary Heart Disease

78

pressure, smoking, abnormal lipid levels, diabetes,

obesity, and sedentary lifestyle. A person’s risk for

CHD events can be estimated based on the

presence of these factors. Calculators are available to

ascertain a person’s risk for having a CHD event;

for example, a calculator to estimate a person’s risk

for a CHD event in the next 10 years can be

accessed at http://hp2010.nhlbihin.net/

atpiii.calculator.asp. Although the exact risk factors

that constitute each of these categories (low or

increased risk) have not been established, younger

adults (i.e., men < 50 years and women < 60 years)

who have no other risk factors for CHD

(< 5%-10% 10-year risk) are considered to be at

low risk. Older adults, or younger adults with 1 or

more risk factors (> 15% -20% 10-year risk), are

considered to be at increased risk.

n Screening with ECG, ETT, and EBCT could

potentially reduce CHD events in 2 ways: either by

detecting people at high risk for CHD events who

could benefit from more aggressive risk factor

modification, or by detecting people with existing

severe CAS whose life could be prolonged by

coronary artery bypass grafting (CABG) surgery.

However, the evidence is inadequate to determine

the extent to which people detected through

screening in either situation would benefit from

either type of intervention.
n The consequences of false-positive tests may

potentially outweigh the benefits of screening. Falsepositive tests are common among asymptomatic

adults, especially women, and may lead to

unnecessary diagnostic testing, over-treatment, and

labeling.

n Because the sensitivity of these tests is limited,

screening could also result in false-negative results.

A negative test does not rule out the presence of

severe CAS or a future CHD event.

n For people in certain occupations, such as pilots

and heavy equipment operators (for whom sudden

incapacitation or sudden death may endanger the

safety of others), considerations other than the

health benefit to the individual patient may

influence the decision to screen for CHD.

n Although some exercise programs initially screen

asymptomatic participants with ETT, there is not

enough evidence to determine the balance of

benefits and harms of this practice.

This USPSTF recommendation was first published in:

Ann Intern Med. 2004; 140:569-572.

Screening for Coronary Heart Disease

79
Using Nontraditional Risk Factors in

Coronary Heart Disease Risk

Assessment

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to assess the balance of benefits and

harms of using the nontraditional risk factors

discussed in this statement to screen asymptomatic

men and women with no history of CHD to

prevent CHD events. Grade: I Statement.

The nontraditional risk factors included in this

recommendation are high-sensitivity C-reactive

protein (hs-CRP), ankle-brachial index (ABI),

leukocyte count, fasting blood glucose level,

periodontal disease, carotid intima-media thickness

(carotid IMT), coronary artery calcification (CAC)

score on electron-beam computed tomography

(EBCT), homocysteine level, and lipoprotein(a)

level.

Clinical Considerations

n The USPSTF intends this recommendation for

asymptomatic men and women with no history of

CHD, diabetes, or any CHD risk equivalent.

n Clinicians should use the Framingham model to

assess CHD risk and to guide risk-based therapy

until further evidence is obtained. (See the Other

Considerations section for a discussion of risk

calculators.)

80
Because adding nontraditional risk factors to CHD

assessment requires additional patient and clinical

staff time and effort, routinely screening with

nontraditional risk factors could result in lost

opportunities for provision of other important

health services of proven benefit.

n This recommendation is to be used for those who

fall into a 10% to 20% (intermediate) 10-year risk

category after being screened for CHD risk by using

traditional CHD risk factors. Using a risk

assessment tool is a key step in managing CHD risk

in patients. One validated method of assessing

CHD risk is the Framingham model. Persons with

low (<10%) Framingham risk scores do not benefit

from aggressive risk factor modification, whereas

those with high (>20%) Framingham risk scores do

benefit. Examples of persons who fall into the

intermediate-risk category include a 60-year-old

male smoker with untreated hypertension or a 60-

year-old female with untreated hypertension and

hyperlipidemia. The current recommendation used

the Adult Treatment Panel III (ATP III)

Framingham risk calculator (available at

http://hp2010.nhlbihin.net/atpiii/calculator.asp?user

type.prof) and does not include diabetic

populations.

n About 31% of asymptomatic U.S. men and 7% of

U.S. women age 40 to 79 years without diabetes

will fall into the intermediate-risk category. No

evidence or consensus is available regarding how to

treat and counsel these persons.

81

Coronary Heart Disease Risk Assessment
Other Considerations

Costs

n Because of limitations in the evidence of

effectiveness, little information is available on the

cost-effectiveness of using nontraditional risk factors

in CHD screening. When the evidence for

effectiveness is clearer, evaluating cost-effectiveness

will be a research priority.

Research Needs and Gaps

n For hs-CRP, ABI, and EBCT, high priority should

be given to determining the benefits and harms of

aggressive treatment of persons reclassified from

intermediate to high risk on the basis of additional

information obtained from these tests.

n For hs-CRP and ABI, future priority should be

given to studies that assess the health effect of

reclassifying those at high and intermediate risk for

CHD events into lower-risk categories on the basis

of this assessment. Similar studies for EBCT would

be useful.

n The predictive value and prevalence of periodontal

disease, carotid IMT, and lipoprotein(a) should be

examined in conjunction with traditional

Framingham risk factors for predicting CHD events

and death.

82

Coronary Heart Disease Risk Assessment
n Various risk models for CHD are available. Some

consider diabetes as a CHD equivalent and others

use it as a risk factor for CHD. The predictive value

and prevalence of nontraditional risk factors for

predicting CHD events and death should be

examined specifically in diabetic populations.

n Several risk calculators are available that use data

from the Framingham studies; 2 of the most

commonly used are the ATP III and the traditional

Framingham risk calculator (available at

www.intmed.mcw.edu/clincalc/heartrisk.html).

Evidence for this recommendation relied on the risk

estimation from the ATP III calculator.

This USPSTF recommendation was first published in:

Ann Intern Med. 2009; 151:474-482.

83

Coronary Heart Disease Risk Assessment
84

Screening for High Blood Pressure

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for high blood

pressure in adults aged 18 and older. Grade: A

Recommendation.

Clinical Considerations

n This recommendation applies to adults without

known hypertension.

n Office measurement of blood pressure is most

commonly done with a sphygmomanometer. High

blood pressure (hypertension) is usually defined in

adults as a systolic blood pressure of 140 mmHg or

higher, or a diastolic blood pressure of 90 mmHg or

higher. Because of the variability in individual blood

pressure measurements, it is recommended that

hypertension be diagnosed only after 2 or more

elevated readings are obtained on at least 2 visits

over a period of 1 to several weeks.

n The relationship between systolic blood pressure

and diastolic blood pressure and cardiovascular risk

is continuous and graded. The actual level of blood

pressure elevation should not be the sole factor in

determining treatment. Clinicians should consider

the patient’s overall cardiovascular risk profile,

including smoking, diabetes, abnormal blood lipid

values, age, sex, sedentary lifestyle, and obesity,

when making treatment decisions.
85

Cancer

n Evidence is lacking to recommend an optimal

interval for screening adults for hypertension. The

seventh report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment

of High Blood Pressure (JNC 7) recommends

screening every 2 years in persons with blood

pressure less than 120/80 mmHg and every year

with systolic blood pressure of 120 to 139 mmHg

or diastolic blood pressure of 80 to 90 mmHg.

n Various pharmacological agents are available to treat

high blood pressure. The JNC 7 guidelines for

treatment of high blood pressure can be accessed at

http://www.nhlbi.nih.gov/guidelines/hypertension/j

ncintro.htm.

n Nonpharmacological therapies, such as reduction of

dietary sodium intake, potassium supplementation,

increased physical activity, weight loss, stress

management, and reduction of alcohol intake, are

associated with a reduction in blood pressure. For

those who consume large amounts of alcohol (>20

drinks per week), studies have shown that reduced

drinking decreases blood pressure.

This USPSTF recommendation was first published in:

Ann Intern Med. 2007; 147:787-791.

Screening for High Blood Pressure
Screening for Lipid Disorders in Adults

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) strongly recommends screening men

aged 35 and older for lipid disorders. Grade: A

Recommendation.

The USPSTF recommends screening men aged

20 to 35 for lipid disorders if they are at increased

risk for coronary heart disease. Grade: B

Recommendation.

The USPSTF strongly recommends screening

women aged 45 and older for lipid disorders if they

are at increased risk for coronary heart disease.

Grade: A Recommendation.

The USPSTF recommends screening women

aged 20 to 45 for lipid disorders if they are at

increased risk for coronary heart disease. Grade: B

Recommendation.

The USPSTF makes no recommendation for or

against routine screening for lipid disorders in men

aged 20 to 35, or in women aged 20 and older

who are not at increased risk for coronary heart

disease. Grade: C Recommendation.

Clinical Considerations

n Lipid disorders, also called dyslipidemias, are

abnormalities of lipoprotein metabolism and

include elevations of total cholesterol, LDL-C, or

triglycerides (TG), or deficiencies of HDL-C. These

86
disorders can be acquired or familial (e.g., familial

hypercholesterolemia). This recommendation

applies to adults aged 20 and older who have not

previously been diagnosed with dyslipidemia.

n Increased risk, for the purposes of this

recommendation, is defined by the presence of any

one of the risk factors listed below. The greatest risk

for CHD is conferred by a combination of multiple

listed factors. While the USPSTF did not use a

specific numerical risk to bound this

recommendation, the framework used by the

USPSTF in making these recommendations relies

on a 10-year risk of cardiovascular events:

– Diabetes.

– Previous personal history of CHD or noncoronary atherosclerosis (e.g., abdominal aortic

aneurysm, peripheral artery disease, carotid

artery stenosis).

– A family history of cardiovascular disease before

age 50 in male relatives or age 60 in female

relatives.

– Tobacco use.

– Hypertension.

– Obesity (BMI ≥30).

n The preferred screening tests for dyslipidemia are

total cholesterol and HDL-C on non-fasting or

fasting samples. There is currently insufficient

evidence of the benefit of including TG as a part of

87

Screening for Lipid Disorders in Adults
the initial tests used to screen routinely for

dyslipidemia. Abnormal screening test results should

be confirmed by a repeated sample on a separate

occasion, and the average of both results should be

used for risk assessment.

n Measuring total cholesterol alone is acceptable for

screening if available laboratory services cannot

provide reliable measurements of HDL-C;

measuring both total cholesterol and HDL-C is

more sensitive and specific for assessing coronary

heart disease risk than measuring total cholesterol

alone. In conjunction with HDL-C, the addition of

either LDL-C or total cholesterol would provide

comparable information, but measuring LDL-C

requires a fasting sample and is more expensive.

Direct LDL-C testing, which does not require a

fasting sample measurement, is now available;

however, calculated LDL (total cholesterol minus

HDL minus TG/5) is the validated measurement

used in trials for risk assessment and treatment

decisions. In patients with dyslipidemia identified

by screening, complete lipoprotein analysis is useful.

n The optimal interval for screening is uncertain. On

the basis of other guidelines and expert opinion,

reasonable options include every 5 years, shorter

intervals for people who have lipid levels close to

those warranting therapy, and longer intervals for

those not at increased risk who have had repeatedly

normal lipid levels.

n An age to stop screening has not been established.

Screening may be appropriate in older people who

88

Screening for Lipid Disorders in Adults
have never been screened; repeated screening is less

important in older people because lipid levels are

less likely to increase after age 65. However, because

older adults have an increased baseline risk for

coronary heart disease, they stand to gain greater

absolute benefit from the treatment of dyslipidemia,

compared with younger adults.

n Treatment decisions should take into account a

person’s overall risk of heart disease rather than lipid

levels alone. Overall risk assessment should include

the presence and severity of the following risk

factors: age, gender, diabetes, elevated blood

pressure, family history (in younger adults), and

smoking. Risk calculators that incorporate specific

information on multiple risk factors provide a more

accurate estimation of cardiovascular risk than tools

that simply count numbers of risk factors.

n Drug therapy is usually more effective than diet

alone in improving lipid profiles, but choice of

treatment should consider overall risk, costs of

treatment, and patient preferences. Guidelines for

treating lipid disorders are available from the

National Cholesterol Education Program of the

National Institutes of Health

(http://www.nhlbi.nih.gov/about/ncep/).

n Although lifestyle modifications (diet and physical

activity) are appropriate initial therapies for most

patients, a minority achieves substantial reductions

in lipid levels from changes in diet alone; drugs are

frequently needed to achieve therapeutic goals,

especially for those at increased risk for coronary

89

Screening for Lipid Disorders in Adults
heart disease. Lipid-lowering treatments should be

accompanied by interventions addressing all

modifiable risk factors for heart disease, including

smoking cessation, treatment of blood pressure,

diabetes, and obesity, as well as promotion of a

healthy diet and regular physical activity. Long-term

adherence to therapies should be emphasized.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. June 2008. http://www.USPreventiveServicesTask

Force.org.

90

Screening for Lipid Disorders in Adults
Clinical Considerations

n The ankle brachial index, a ratio of Dopplerrecorded systolic pressures in the lower and upper

extremities, is a simple and accurate noninvasive

test for the screening and diagnosis of PAD. The

ankle brachial index has demonstrated better

accuracy than other methods of screening,

including history-taking, questionnaires, and

palpation of peripheral pulses. An ankle-brachial

index value of less than 0.90 (95% sensitive and

specific for angiographic PAD) is strongly

associated with limitations in lower extremity

functioning and physical activity tolerance.

n Smoking cessation and lipid-lowering agents

improve claudication symptoms and lower

extremity functioning among patients with

symptomatic PAD. Smoking cessation and

physical activity training also increase maximal

walking distance among men with early PAD.

Counseling for smoking cessation, however,

should be offered to all patients who smoke,

regardless of the presence of PAD. Similarly,

Screening for Peripheral Arterial

Disease

91

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine screening

for peripheral arterial disease (PAD). Grade: D

Recommendation.
Screening for Peripheral Arterial Disease

physically inactive patients should be counseled to

increase their physical activity, regardless of the

presence of PAD.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville, MD.

August 2005. http://www.USPreventiveServicesTask

Force.org.

92
93

Infectious Diseases

Screening for Asymptomatic Bacteriuria

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for

asymptomatic bacteriuria with urine culture for

pregnant women at 12 to 16 weeks’ gestation or at

the first prenatal visit, if later. Grade: A

Recommendation.

The USPSTF recommends against screening for

asymptomatic bacteriuria in men and nonpregnant

women. Grade: D Recommendation.

Clinical Considerations

n This recommendation applies to the general adult

population, including adults with diabetes. The

USPSTF did not review evidence for screening

certain groups at high risk for severe urinary tract

infections, such as transplant recipients, patients

with sickle cell disease, and patients with recurrent

urinary tract infections.

n The screening tests used commonly in the primary

care setting (dipstick analysis and direct

microscopy) have poor positive and negative

predictive value for detecting bacteriuria in
Screening for Asymptomatic Bacteriuria

94

asymptomatic persons. Urine culture is the gold

standard for detecting asymptomatic bacteriuria but

is expensive for routine screening in populations

with a low prevalence of the condition. However,

no currently available tests have a high enough

sensitivity and negative predictive value in pregnant

women to replace the urine culture as the preferred

screening test.

n Pregnant women with asymptomatic bacteriuria

should receive antibiotic therapy directed at the

cultured organism and follow-up monitoring.

n All pregnant women should provide a clean-catch

urine specimen for a screening culture at 12 to 16

weeks’ gestation or at the first prenatal visit, if later.

The optimal frequency of subsequent urine testing

during pregnancy is uncertain.

This USPSTF recommendation was first published in:

Ann Intern Med. 2008; 149:43-47.
95

Screening for Chlamydial Infection

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for chlamydial

infection for all sexually active non-pregnant young

women aged 24 and younger and for older nonpregnant women who are at increased risk. Grade:

A Recommendation.

The USPSTF recommends screening for

chlamydial infection for all pregnant women aged

24 and younger and for older pregnant women

who are at increased risk. Grade: B

Recommendation.

The USPSTF recommends against routinely

providing screening for chlamydial infection for

women aged 25 and older, whether or not they are

pregnant, if they are not at increased risk. Grade: C

Recommendation.

The USPSTF concludes that the current

evidence is insufficient to assess the balance of

benefits and harms of screening for chlamydial

infection for men. Grade: I Statement.

Clinical Considerations

n These recommendations target all sexually active

individuals, including adolescents and pregnant

women.
Screening for Chlamydial Infection

n All sexually active women 24 years of age or

younger, including adolescents, are at increased risk

for chlamydial infection. In addition to sexual

activity and age, other risk factors for chlamydial

infection include a history of chlamydial or other

sexually transmitted infection, new or multiple

sexual partners, inconsistent condom use, and

exchanging sex for money or drugs. Risk factors for

pregnant women are the same as for nonpregnant

women.

n Prevalence of chlamydial infection varies widely

among patient populations. African-American and

Hispanic women have a higher prevalence of

infection than the general population in many

communities and settings. Among men and

women, increased prevalence rates are also found in

incarcerated populations, military recruits, and

patients at public sexually transmitted infection

clinics.

n Nucleic acid amplification tests have high specificity

and sensitivity when used as screening tests for

chlamydial infection. Nucleic acid amplification

tests can be used with urine and vaginal swabs,

enabling screening when a pelvic examination is not

performed.

n Appropriate treatment of chlamydial infection has

been outlined by the Centers for Disease Control

and Prevention (CDC). In its 2006 sexually

96
transmitted disease treatment guidelines, the CDC

recommends that chlamydia infection be treated

with 1 g of azithromycin in a single oral dose or

with oral doxycycline, 100 mg twice daily for 7

days. Pregnant women with chlamydial infection

may be treated with 1 g of azithromycin in a single

oral dose or amoxicillin, 500 mg orally 3 times daily

for 7 days.

1 Because the CDC updates these

recommendations regularly, clinicians are

encouraged to access the CDC Web site

(http://www.cdc.gov/std/treatment/) to obtain the

most up-to-date information.

n To prevent recurrent transmission, clinicians should

ensure that all sexual partners of infected individuals

are tested and treated if infected, or treated

presumptively.

n Screening for pregnant women who are at increased

risk for chlamydial infection is recommended at the

first prenatal visit. For pregnant women who remain

at increased risk and for those who acquire a new

risk factor, such as a new sexual partner, a screening

should be conducted during the third trimester. The

optimal interval for screening nonpregnant women

is unknown. The CDC recommends at least annual

screening for women at increased risk.

n The USPSTF concluded that the evidence is

insufficient to determine the balance of benefits and

harms related to screening men for chlamydial

infection. Specifically, the USPSTF did not find

evidence that screening programs that target men

97

Screening for Chlamydial Infection
98

Screening for Chlamydial Infection

result in a decreased incidence of infection in

women.

The USPSTF notes that programs that screen men

as a means of reducing transmission to women are

not common practice, that primary care clinicians

can institute screening in men, that the costs of

additional screening tests per individual are

relatively low, and that the potential harms of

screening are small.

The USPSTF recognizes that asymptomatic,

untreated infections in men provide a reservoir of

infection that may make it difficult to improve

health outcomes in women through screening

programs that target only women. However, given

the low national rates of screening in women at risk,

the USPSTF believes that clinicians and health care

systems should focus on improving the screening

rates among women at increased risk, a group in

which the benefits of screening are certain.

n Primary care clinicians and the health care systems

in which they work are responsible for ensuring that

asymptomatic women at risk for chlamydial

infection are screened. In some communities, this

may involve home- or school-based screening

programs.

This USPSTF recommendation was first published in:

Ann Intern Med. 2007; 147:128-33.
99

Screening for Genital Herpes

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine serological

screening for herpes simplex virus (HSV) in

asymptomatic pregnant women at any time during

pregnancy to prevent neonatal HSV infection.

Grade: D Recommendation.

The USPSTF recommends against routine

serological screening for HSV in asymptomatic

adolescents and adults. Grade: D Recommendation.

Clinical Considerations

n Serological screening tests for genital herpes can

detect prior infection with HSV in asymptomatic

persons, and new type-specific serological tests can

differentiate between HSV-1 and HSV-2 exposure

(these tests cannot differentiate between oral vs.

genital herpes exposure); however, given the natural

history of genital herpes, there is limited evidence to

guide clinical intervention in those asymptomatic

persons who have positive serological test results.

False-positive test results may lead to labeling and

psychological stress without any potential benefit to

patients. Negative test results (both false-negative

and true-negative results) may provide false

reassurance to continue high-risk sexual behaviors.

n There is new, good-quality evidence demonstrating

that systemic antiviral therapy effectively reduces

viral shedding and recurrences of genital herpes in
Screening for Genital Herpes

adolescents and adults with a history of recurrent

genital herpes. There are multiple efficacious

regimens that may be used to prevent the recurrence

of clinical genital herpes.

n The USPSTF did not examine the evidence for the

effectiveness of counseling to avoid high-risk sexual

behavior in persons with a history of genital herpes

to prevent transmission to discordant partners, or

for the primary prevention of genital herpes in

persons not infected with HSV. There are known

health benefits of avoiding high-risk sexual

behavior, including prevention of sexually

transmitted infections (STIs) and HIV infection.

n Primary HSV infection during pregnancy presents

the greatest risk for transmitting infection to the

newborn. The fact that women with primary HSV

infection are initially seronegative limits the

usefulness of screening with antibody tests. The

USPSTF did not find any studies testing the use of

antibody screening to find and treat seronegative

pregnant women (i.e., those at risk for primary

HSV infection) prophylactically. However, the

number of seronegative pregnant women one would

need to treat to theoretically avoid one primary

infection would be very high, making the potential

benefit small. At the same time, the potential harm

to many low-risk women and fetuses from the side

effects of antiviral therapy may be great.

100
Screening for Genital Herpes

n There is fair evidence that antiviral therapy in late

pregnancy can reduce HSV recurrence and viral

shedding at delivery in women with recurrent HSV

infection; however, there is currently no evidence

that antiviral use in women with a history of HSV

leads to reduced neonatal infection. Likewise, there

is limited information on the benefits of screening

women in labor for signs of active genital HSV

lesions, and for the performance of cesarean delivery

on those with lesions.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality. Rockville,

MD. March 2005. http://www.USPreventiveServicesTask

Force.org.

101
102

Screening for Gonorrhea

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends that clinicians screen all

sexually active women, including those who are

pregnant, for gonorrhea infection if they are at

increased risk for infection (that is, if they are young

or have other individual or population risk factors;

see Clinical Considerations for further discussion of

risk factors). Grade: B Recommendation.

The USPSTF found insufficient evidence to

recommend for or against routine screening for

gonorrhea infection in men at increased risk for

infection (see Clinical Considerations for discussion

of risk factors). Grade: I Statement.

The USPSTF recommends against routine

screening for gonorrhea infection in men and

women who are at low risk for infection (see

Clinical Considerations for discussion of risk

factors). Grade: D Recommendation.

The USPSTF found insufficient evidence to

recommend for or against routine screening for

gonorrhea infection in pregnant women who are

not at increased risk for infection (see Clinical

Considerations for discussion of risk factors). Grade:

I Statement.

The USPSTF strongly recommends prophylactic

ocular topical medication for all newborns against

gonococcal ophthalmia neonatorum.

Grade: A Recommendation.
Screening for Gonorrhea

103

Clinical Considerations

n Women and men under the age of 25—including

sexually active adolescents—are at highest risk for

genital gonorrhea infection. Risk factors for

gonorrhea include a history of previous gonorrhea

infection, other sexually transmitted infections, new

or multiple sexual partners, inconsistent condom

use, sex work, and drug use. Risk factors for

pregnant women are the same as for non-pregnant

women. Prevalence of gonorrhea infection varies

widely among communities and patient

populations. African Americans and men who have

sex with men have a higher prevalence of infection

than the general population in many communities

and settings.

n Individual risk depends on the local epidemiology

of disease. Local public health authorities provide

guidance to clinicians to help identify populations

who are at increased risk in their communities. In

communities with a high prevalence of gonorrhea,

broader screening of sexually active young people

may be warranted, especially in settings serving

individuals who are at increased risk. Additionally,

clinicians may want to consider other populationbased risk factors, including residence in urban

communities and communities with high rates of

poverty, when making screening decisions. Low

community prevalence of gonorrhea infection may

justify more targeted screening.
Screening for Gonorrhea

104

n Screening is recommended at the first prenatal visit

for pregnant women who are in a high risk group

for gonorrhea infection. For pregnant patients who

are at continued risk, and for those who acquire a

new risk factor, a second screening should be

conducted during the third trimester. The optimal

interval for screening in the non-pregnant

population is not known.

n Vaginal culture remains an accurate screening test

when transport conditions are suitable. Newer

screening tests, including nucleic acid amplification

tests and nucleic acid hybridization tests, have

demonstrated improved sensitivity and comparable

specificity when compared with cervical culture.

Some newer tests can be used with urine and

vaginal swabs, which enables screening when a

pelvic examination is not performed.

n Appropriate treatment of gonorrhea infection and

administration of prophylactic medication to

newborns have been outlined by the Centers for

Disease Control and Prevention (CDC)

(http://www.cdc.gov/std/treatment/42002TG.htm#

Gonococcal). Genital infection in men and women

may be treated with a third generation

cephalosporin or fluoroquinolone, and pregnant

women may be treated with third generation

cephalosporins. Because of emerging

fluoroquinolone resistance, the CDC issued new

treatment guidelines in 2004 recommending that
Screening for Gonorrhea

men who have sex with men and those who

acquired an infection in California, Hawaii, or Asia

not be treated with fluoroquinolone antibiotics. If

clinicians have not concurrently screened for

chlamydial infection, the CDC recommends

presumptive treatment for chlamydia at the time of

treatment for gonorrhea. In order to prevent

recurrent transmission, partners of infected

individuals should be tested and treated if infected,

or treated presumptively.

n Gonorrhea is a nationally reportable condition.

More complete reporting of gonorrhea cases to

public health authorities will permit more accurate

estimations of gonorrhea prevalence. Improved

information will allow clinicians to screen for

gonorrhea in ways that improve the balance

between benefits and harms for their patients.

n Research priorities for gonorrhea screening include

greater understanding of the benefits of screening

men at increased risk, especially men who have sex

with men, and the role of reporting on gonorrhea

rates and testing priorities.

This USPSTF recommendation was first published in:

Ann Fam Med. 2005; 3:263-267.

105
106

Screening for Hepatitis B Virus

Infection

NOTE: Please see the updated Screening for Hepatitis

B Virus Infection in Pregnancy on p. 108.

Summary of Recommendations

The USPSTF recommends against routinely

screening the general asymptomatic population for

chronic hepatitis B virus infection. Grade: D

Recommendation.

Clinical Considerations

n Routine hepatitis vaccination has had significant

impact in reducing the number of new HBV

infections per year, with the greatest decline among

children and adolescents. Programs that vaccinate

health care workers also reduce the transmission of

HBV infection.

n Most people who become infected as adults or older

children recover fully from HBV infection and

develop protective immunity to the virus.

n The main risk factors for HBV infection in the

United States include diagnosis with a sexually

transmitted disease, intravenous drug use, sexual

contact with multiple partners, male homosexual

activity, and household contacts of chronically

infected persons. However, screening strategies to

identify individuals at high risk have poor predictive

value, since 30% to 40% of infected individuals do

not have any easily identifiable risk factors.
Screening for Hepatitis B Virus Infection

n Important predictors of progressive HBV infection

include longer duration of infection and the

presence of comorbid conditions such as alcohol

abuse, HIV, or other chronic liver disease.

Individuals with HBV infection identified through

screening may benefit from interventions designed

to reduce liver injury from other causes, such as

counseling to avoid alcohol abuse and

immunization against hepatitis A. However, there is

limited evidence on the effectiveness of these

interventions.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville, MD.

February 2004. http://www.USPreventiveServicesTask

Force.org.

107
Screening for Hepatitis B Virus

Infection in Pregnancy

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for hepatitis B

virus (HBV) infection in pregnant women at their

first prenatal visit. Grade: A Recommendation.

Clinical Considerations

n This recommendation statement applies to all

pregnant women.

n Screening for HBV infection by testing for HBsAg

should be performed in each pregnancy, regardless

of previous hepatitis B vaccination or previous

negative HBsAg test results.

n A test for HBsAg should be ordered at the first

prenatal visit with other recommended screening

tests. At the time of admission to a hospital, birth

center, or other delivery setting, women with

unknown HBsAg status or with new or continuing

risk factors for HBV infection (such as injection

drug use or evaluation or treatment for a sexually

transmitted disease) should receive screening.

n Infants born to HBV-infected mothers should

receive hepatitis B vaccine and hepatitis B immune

globulin within 12 hours of birth. Infants born to

mothers with unknown HBsAg status should

receive hepatitis B vaccine within 12 hours of birth,

followed by hepatitis B immune globulin as soon as

108
possible (but not later than 7 days after birth) if the

mother tests positive for HBsAg.

Pregnant women who test positive for HBsAg

should be referred to an appropriate case-management

program and should be provided with or referred for

counseling and medical management of HBV

infection. Counseling should include information

about prevention of HBV transmission to sexual

partners and household contacts and reassurance

regarding the safety of breastfeeding in infants who

receive appropriate prophylaxis.

This USPSTF recommendation was first published in:

Ann Intern Med. 2009; 150:869-873.

109

Screening for Hepatitis B Virus Infection in Pregnancy
Screening for Hepatitis C in Adults

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine screening

for hepatitis C virus (HCV) infection in

asymptomatic adults who are not at increased risk

(general population) for infection. Grade: D

Recommendation.

The USPSTF found insufficient evidence to

recommend for or against routine screening for

HCV infection in adults at high risk for infection.

Grade: I Statement.

Clinical Considerations

n Established risk factors for HCV infection include

current or past intravenous drug use, transfusion

before 1990, dialysis, and being a child of an HCVinfected mother. Surrogate markers, such as highrisk sexual behavior (particularly sex with someone

infected with HCV) and the use of illegal drugs,

such as cocaine or marijuana, have also been

associated with increased risk for HCV infection.

The proportion of people who received blood or

blood product transfusions before 1990 will

continue to decline, and HCV infection will be

associated mainly with intravenous drug use and, to

some extent, unsafe sexual behaviors.

110
n Initial testing for HCV infection is typically done

by enzyme immunoassay (EIA). In a population

with a low prevalence of HCV infection (e.g., 2%),

approximately 59% of all positive tests using the

third-generation EIA test with 97% specificity

would be false positive. As a result, confirmatory

testing is recommended with the strip recombinant

immunoblot assay (third-generation RIBA).

n Important predictors of progressive HCV infection

include older age at acquisition; longer duration of

infection; and presence of comorbid conditions,

such as alcohol misuse, HIV infection, or other

chronic liver disease. Asymptomatic individuals

with HCV infection identified through screening

may benefit from interventions designed to reduce

liver injury from other causes, such as counseling to

avoid alcohol misuse and immunization against

hepatitis A and hepatitis B. However, there is

limited evidence of the effectiveness of these

interventions.

This USPSTF recommendation was first published in:

Ann Intern Med. 2004; 140(6):462-464.

111

Screening for Hepatitis C in Adults
Screening for HIV

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) strongly recommends that clinicians

screen for human immunodeficiency virus (HIV)

all adolescents and adults at increased risk for HIV

infection. Grade: A Recommendation.

The USPSTF makes no recommendation for or

against routinely screening for HIV adolescents

and adults who are not at increased risk for HIV

infection. Grade: C Recommendation.

The USPSTF recommends that clinicians screen

all pregnant women for HIV. Grade: A

Recommendation.

Clinical Considerations

n A person is considered at increased risk for HIV

infection (and thus should be offered HIV testing)

if he or she reports 1 or more individual risk factors

or receives health care in a high-prevalence or highrisk clinical setting.

n Individual risk for HIV infection is assessed through

a careful patient history. Those at increased risk (as

determined by prevalence rates) include: men who

have had sex with men after 1975; men and women

having unprotected sex with multiple partners; past

or present injection drug users; men and women

who exchange sex for money or drugs or have sex

partners who do; individuals whose past or present

sex partners were HIV-infected, bisexual, or

112
Screening for HIV

113

injection drug users; persons being treated for

sexually transmitted diseases (STDs); and persons

with a history of blood transfusion between 1978

and 1985. Persons who request an HIV test despite

reporting no individual risk factors may also be

considered at increased risk, since this group is

likely to include individuals not willing to disclose

high risk behaviors.

n There is good evidence of increased yield from

routine HIV screening of persons who report no

individual risk factors but are seen in high-risk or

high-prevalence clinical settings. High-risk settings

include STD clinics, correctional facilities, homeless

shelters, tuberculosis clinics, clinics serving men

who have sex with men, and adolescent health

clinics with a high prevalence of STDs. Highprevalence settings are defined by the Centers for

Disease Control and Prevention (CDC) as those

known to have a 1% or greater prevalence of

infection among the patient population being

served. Where possible, clinicians should consider

the prevalence of HIV infection or the risk

characteristics of the population they serve in

determining an appropriate screening strategy. Data

are currently lacking to guide clinical decisions

about the optimal frequency of HIV screening.

n Current evidence supports the benefit of identifying

and treating asymptomatic individuals in

immunologically advanced stages of HIV disease

(CD4 cell counts < 200 cells/mm3) with highly

active antiretroviral therapy (HAART). Appropriate
Screening for HIV

114

prophylaxis and immunization against certain

opportunistic infections have also been shown to be

effective interventions for these individuals. Use of

HAART can be considered for asymptomatic

individuals who are in an earlier stage of disease but

at high risk for disease progression (CD4 cell count

< 350 cells/mm3 or viral load > 100,000

copies/mL), although definitive evidence of a

significant benefit of starting HAART at these

counts is currently lacking.

n The standard test for diagnosing HIV infection, the

repeatedly reactive enzyme immunoassay followed

by confirmatory western blot or immunofluorescent

assay, is highly accurate (sensitivity and specificity >

99%). Rapid HIV antibody testing is also highly

accurate; can be performed in 10 to 30 minutes;

and, when offered at the point of care, is useful for

screening high risk patients who do not receive

regular medical care (e.g., those seen in emergency

departments), as well as women with unknown

HIV status who present in active labor.

n Early identification of maternal HIV seropositivity

allows early antiretroviral treatment to prevent

mother-to-child transmission, allows providers to

avoid obstetric practices that may increase the risk

for transmission, and allows an opportunity to

counsel the mother against breastfeeding (also

known to increase the risk for transmission). There

is evidence that the adoption of “opt-out” strategies

to screen pregnant women (who are informed that

an HIV test will be conducted as a standard part of
Screening for HIV

prenatal care unless they decline it) has resulted in

higher testing rates. However, ethical and legal

concerns of not obtaining specific informed consent

for an HIV test using the “opt-out” strategy have

been raised. While dramatic reductions in HIV

transmission to neonates have been noted as a result

of early prenatal detection and treatment, the extent

to which detection of HIV infection and

intervention during pregnancy may improve longterm maternal outcomes is unclear.

This USPSTF recommendation was first published in:

Ann Intern Med. 2005; 143:32-37.

115
Behavioral Counseling to Prevent

Sexually Transmitted Infections

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends high-intensity behavioral

counseling to prevent sexually transmitted

infections (STIs) for all sexually active adolescents

and for adults and increased risk for STIs. Grade: B

Recommendation.

The USPSTF concludes that the current

evidence is insufficient to assess the balance of

benefits and harms of behavioral counseling to

prevent STIs in non-sexually-active adolescents and

in adults not at increased risk for STIs. Grade: I

Statement.

Clinical Considerations

n This recommendation applies to all sexually active

adolescents and adults.

n All sexually active adolescents are at increased risk

for STIs and should be offered counseling. Adults

with current STIs or infections within the past year

are at increased risk for future STIs. In addition,

adults who have multiple current sexual partners

should be considered at increased risk and offered

116
Counseling to Prevent Sexually Transmitted Infections

counseling to prevent STIs. Married adolescents

may be considered for counseling if they meet the

criteria described for adults. Clinicians should also

consider the communities they serve. If the

practice’s population has a high rate of STIs, all

sexually active patients in nonmonogamous

relationships may be considered to be at increased

risk.

n Among the studies reviewed, successful highintensity interventions were delivered through

multiple sessions, most often in groups, with total

durations from 3 to 9 hours. Little evidence

suggests that single-session interventions or

interventions lasting less than 30 minutes were

effective in reducing STIs. Although 2 studies of

moderate-intensity interventions did not

demonstrate effect, a third study demonstrated that

two 20-minute counseling sessions before and after

HIV testing resulted in a clinically and statistically

significant reduction in STIs. The USPSTF found

no studies of abstinence-only counseling programs

delivered in the clinical setting.

n Because of the lower incidence of STIs among

adults who are not at increased risk, the potential

net benefit of behavioral counseling is likely to be

smaller for this population than for those at

increased risk. Given the current lack of evidence of

effectiveness; the substantial costs in time and

money for clinicians, patients, and the health

117
system; and the potential missed opportunity for

the provision of higher-priority, evidence-based

preventive services, primary care clinicians should

consider not routinely offering behavioral

counseling to prevent STIs to adults who are not at

increased risk for infection. The USPSTF found

limited evidence on the counseling of non-sexuallyactive adolescents, with no effect or harms from

brief counseling in 1 small study. Although

clinicians may not be able to identify all adolescents

who are sexually active, intensive counseling for all

adolescents to reach those who are not appropriately

identified as at risk is not supported by current

evidence and would require significant resources.

The effectiveness of less intensive counseling has

not been established and the benefits of intensive

counseling for adolescents who are identified as at

risk may not be generalizable to those who deny

sexual activity.

This USPSTF recommendation was first published in:

Ann Intern Med. 2008; 149(7):491-497.

118

Counseling to Prevent Sexually Transmitted Infections
Screening for Syphilis Infection

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation. Please see the updated Screening for

Syphilis Infection in Pregnancy on p. 122.

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) strongly recommends that clinicians

screen persons at increased risk for syphilis

infection. Grade: A Recommendation.

The USPSTF recommends against routine

screening of asymptomatic persons who are not at

increased risk for syphilis infection. Grade: D

Recommendation.

Clinical Considerations

n Populations at increased risk for syphilis infection

(as determined by incident rates) include men who

have sex with men and engage in high-risk sexual

behavior, commercial sex workers, persons who

exchange sex for drugs, and those in adult

correctional facilities. There is no evidence to

support an optimal screening frequency in this

population. Clinicians should consider the

characteristics of the communities they serve in

119
Screening for Syphilis Infection

determining appropriate screening strategies.

Prevalence of syphilis infection varies widely

among communities and patient populations.

For example, the prevalence of syphilis infection

differs by region (the prevalence of infection is

higher in the southern U.S. and in some

metropolitan areas than it is in the U.S. as a

whole) and by ethnicity (the prevalence of

syphilis infection is higher in Hispanic and

African American populations than it is in the

white population).

n Persons diagnosed with other sexually

transmitted diseases (STDs) (i.e., chlamydia,

gonorrhea, genital herpes simplex, human

papilloma virus, and HIV) may be more likely

than others to engage in high-risk behavior,

placing them at increased risk for syphilis;

however, there is no evidence that supports the

routine screening of individuals diagnosed with

other STDs for syphilis infection. Clinicians

should use clinical judgment to individualize

screening for syphilis infection based on local

prevalence and other risk factors (see above).

n Nontreponemal tests commonly used for initial

screening are the Venereal Disease Research

Laboratory (VDRL) or Rapid Plasma Reagin

(RPR), followed by a confirmatory fluorescent

120
Screening for Syphilis Infection

121

treponemal antibody absorbed (FTA-ABS) or T.

pallidum particle agglutination (TP-PA). The

optimal screening interval in average- and high-risk

persons has not been determined.

This USPSTF recommendation was first published in:

Ann Fam Med. 2004; 2(4):362-365.
Screening for Syphilis Infection in

Pregnancy

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends that clinicians screen all

pregnant women for syphilis infection. Grade: A

Recommendation.

Clinical Considerations

n This recommendation applies to pregnant women.

n Pregnant women who are at increased risk for

syphilis infection include uninsured women,

women living in poverty, sex workers, illicit drug

users, and women in communities with high

syphilis morbidity. The prevalence of syphilis

infection differs by region (it is higher in the

southern United States and in some metropolitan

areas than it is in the United States as a whole) and

by ethnicity (it is higher in Hispanic and AfricanAmerican populations than in the white

population). Persons in whom sexually transmitted

diseases have been diagnosed may be more likely

than others to engage in high-risk behavior, which

places them at increased risk for syphilis.

n Nontreponemal tests commonly used for initial

screening are the Venereal Disease Research

Laboratory (VDRL) test or the Rapid Plasma

Reagin (RPR) test. These are typically followed by a

confirmatory fluorescent treponemal antibody

122
absorbed test or Treponema pallidum particle

agglutination test (TPPA).

n The Centers for Disease Control and Prevention

(CDC) has outlined appropriate treatment of

syphilis in pregnancy (http://www.cdc.gov/std/

treatment/). In its 2006 sexually transmitted disease

treatment guidelines, the CDC recommends

parenteral benzathine penicillin G for the treatment

of syphilis in pregnancy. Evidence on the efficacy or

safety of alternative antibiotics in pregnancy is

limited; therefore, women who report penicillin

allergies should be evaluated for penicillin allergies

and, if present, desensitized and treated with

penicillin. Because the CDC updates these

recommendations regularly, clinicians are

encouraged to access the CDC Web site

(http://www.cdc.gov/std/treatment/) to obtain the

most up-to-date information.

n All pregnant women should be tested at their first

prenatal visit. For women in high-risk groups, many

organizations recommend repeat serologic testing in

the third trimester and at delivery. Most states

mandate that all pregnant women be screened at

some point during pregnancy, and many mandate

screening at the time of delivery. Follow-up

serologic tests should be obtained after treatment to

document decline in titers. To ensure that results are

comparable, follow-up tests should be performed by

using the same nontreponemal test that was used

initially to document the infection (for example,

VDRL or RPR).

123

Screening for Syphilis Infection in Pregnancy
n The USPSTF has made recommendations on

screening for other sexually transmitted diseases in

pregnancy, including gonorrhea, chlamydial

infection, hepatitis B, herpes, and HIV. Please go to

the USPSTF Web site

(http://www.USPreventiveServicesTaskForce.org) for

more information on these recommendations. The

CDC guidelines on treatment for syphilis in

pregnancy can be accessed at

http://www.cdc.gov/std/treatment/.

This USPSTF recommendation was first published in:

Ann Intern Med. 2009; 150:705-709.

124

Screening for Syphilis Infection in Pregnancy
125

Clinical Considerations

n The USPSTF did not review the evidence for the

effectiveness of case-finding tools; however, all

clinicians examining children and adults should be

alert to physical and behavioral signs and symptoms

associated with abuse or neglect. Patients in whom

abuse is suspected should receive proper

documentation of the incident and physical

Injury and Violence

Screening for Family and Intimate

Partner Violence

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) found insufficient evidence to

recommend for or against routine screening of

parents or guardians for the physical abuse or

neglect of children, of women for intimate partner

violence, or of older adults or their caregivers for

elder abuse. Grade: I Statement.
Screening for Family and Intimate Partner Violence

126

findings (e.g., photographs, body maps); treatment

for physical injuries; arrangements for skilled

counseling by a mental health professional; and the

telephone numbers of local crisis centers, shelters,

and protective service agencies.

n Victims of family violence are primarily children,

female spouses/intimate partners, and older adults.

Numerous risk factors for family violence have been

identified, although some may be confounded by

socioeconomic factors. Factors associated with child

abuse or neglect include low income status, low

maternal education, non-white race, large family

size, young maternal age, single-parent household,

parental psychiatric disturbances, and presence of a

stepfather. Factors associated with intimate partner

violence include young age, low income status,

pregnancy, mental health problems, alcohol or

substance use by victims or perpetrators, separated

or divorced status, and history of childhood sexual

and/or physical abuse. Factors associated with the

abuse of older adults include increasing age, nonwhite race, low income status, functional

impairment, cognitive disability, substance use, poor

emotional state, low self-esteem, cohabitation, and

lack of social support.

n Several instruments to screen parents for child abuse

have been studied, but their ability to predict child

abuse or neglect is limited. Instruments to screen

for intimate partner violence have also been

developed, and although some have demonstrated
Screening for Family and Intimate Partner Violence

127

good internal consistency (e.g., the HITS [Hurt,

Insulted, Threatened, Screamed at] instrument, the

Partner Abuse Interview, and the Women’s

Experience with Battering [WEB] Scale), none have

been validated against measurable outcomes. Only a

few screening instruments (the Caregiver Abuse

Screen [CASE] and the Hwalek-Sengstock Elder

Abuse Screening Test [HSEAST]) have been

developed to identify potential older victims of

abuse or their abusive caretakers. Both of these tools

correlated well with previously validated

instruments when administered in the community,

but have not been tested in the primary care clinical

setting.

n Home visit programs directed at high-risk mothers

(identified on the basis of sociodemographic risk

factors) have improved developmental outcomes

and decreased the incidence of child abuse and

neglect, as well as decreased rates of maternal

criminal activity and drug use.

This USPSTF recommendation was first published in:

Ann Intern Med. 2004; 140(5):382-386.
Counseling About Proper Use of Motor

Vehicle Occupant Restraints and

Avoidance of Alcohol Use While Driving

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) concludes that the current evidence is

insufficient to assess the incremental benefit,

beyond the efficacy of legislation and communitybased interventions, of counseling in the primary

care setting, in improving rates of proper use of

motor vehicle occupant restraints (child safety

seats, booster seats, and lap-and-shoulder belts).

Grade: I Statement.

The USPSTF concludes that the current

evidence is insufficient to assess the balance of

benefits and harms of routine counseling of all

patients in the primary care setting to reduce

driving while under the influence of alcohol or

riding with drivers who are alcohol-impaired.

Grade: I Statement.

128

Clinical Considerations

n This recommendation refers to behavioral

counseling interventions performed in the primary

care setting, addressing parents of all infants and

children, children, adolescents, and adults.

n The injury prevention benefits of child safety seat

and booster seat use require proper use. (That is,

the seats should be age- and weight-appropriate and
Counseling About Motor Vehicle Occupant Restraints

129

should be installed and placed into the vehicle

correctly.) Infants younger than 1 year of age and

weighing fewer than 20 pounds should be placed in

rear-facing, infant-only car safety seats or

convertible seats positioned in the back seat. Infants

younger than 1 year of age and weighing between

20 and 35 pounds should be placed in rear-facing

convertible seats positioned in the back seat. Rearfacing child safety seats must not be placed in the

front passenger seat of any vehicle that is equipped

with an airbag on the front passenger side. Death or

serious injury can result from the impact of the

airbag against the child safety seat. Toddlers 1 to 4

years of age weighing 20 to 40 pounds should be

restrained in a forward-facing convertible seat or

forward-facing-only seat positioned in the back seat.

Young children 4 to 8 years of age and up to 4’9”

(57 inches) in height should be placed in a booster

seat in the back seat. After this age (or height), lapand-shoulder belt use is appropriate. Children

younger than 13 years of age should sit in the back

seat with lap-and-shoulder belts.

n Behavioral counseling interventions that include an

educational component, as well as a demonstration

of use or a distribution component, are more

effective than those that include education alone.

n Clinical counseling in conjunction with

community-based interventions has been effective

in increasing proper use of child safety seats. Over

the past decade, legislation and enforcement have
130

Counseling About Motor Vehicle Occupant Restraints

contributed substantially to the increasing trends in

child safety seat and seat belt use. A comprehensive

strategy that includes community-based

interventions, primary care counseling in the

primary care setting, legislation, and enforcement is

critical to the improvement of proper safety

restraint use and decrease in the incidence of

MVOI.

This USPSTF recommendation was first published in:

Ann Intern Med. 2007; 147:187-193.
Clinical Considerations

n Alcohol misuse includes “risky/hazardous” and

“harmful” drinking that places individuals at risk

for future problems. “Risky” or “hazardous”

drinking has been defined in the United States as

more than 7 drinks per week or more than 3 drinks

per occasion for women, and more than 14 drinks

per week or more than 4 drinks per occasion for

131

Mental Health Conditions and

Substance Abuse

Screening and Behavioral Counseling

Interventions in Primary Care to

Reduce Alcohol Misuse

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening and behavioral

counseling interventions to reduce alcohol misuse

(go to Clinical Considerations) by adults,

including pregnant women, in primary care

settings. Grade: B Recommendation.

The USPSTF concludes that the evidence is

insufficient to recommend for or against screening

and behavioral counseling interventions to prevent

or reduce alcohol misuse by adolescents in primary

care settings. Grade: I Statement.
men. “Harmful drinking” describes persons who are

currently experiencing physical, social, or

psychological harm from alcohol use but do not

meet criteria for dependence.Alcohol abuse and

dependence are associated with repeated negative

physical, psychological, and social effects from

alcohol. The USPSTF did not evaluate the

effectiveness of interventions for alcohol

dependence because the benefits of these

interventions are well established and referral or

specialty treatment is recommended for those

meeting the diagnostic criteria for dependence.

n Light to moderate alcohol consumption in middleaged or older adults has been associated with some

health benefits, such as reduced risk for coronary

heart disease. Moderate drinking has been defined

as 2 standard drinks (e.g., 12 ounces of beer) or less

per day for men and 1 drink or less per day for

women and persons older than 65, but recent data

suggest comparable benefits from as little as 1 drink

3 to 4 times a week.

n The Alcohol Use Disorders Identification Test

(AUDIT) is the most studied screening tool for

detecting alcohol-related problems in primary care

settings. It is sensitive for detecting alcohol misuse

and abuse or dependence and can be used alone or

embedded in broader health risk or lifestyle

assessments. The 4-item CAGE (feeling the need to

Cut down, Annoyed by criticism, Guilty about

drinking, and need for an Eye-opener in the

morning) is the most popular screening test for

Alcohol Misuse

132
detecting alcohol abuse or dependence in primary

care. The TWEAK, a 5-item scale, and the T-ACE

are designed to screen pregnant women for alcohol

misuse. They detect lower levels of alcohol

consumption that may pose risks during pregnancy.

Clinicians can choose screening strategies that are

appropriate for their clinical population and setting.

Screening tools are available at the National

Institute on Alcohol Abuse and Alcoholism Web

site: http://www.niaaa.nih.gov/.

n Effective interventions to reduce alcohol misuse

include an initial counseling session of about 15

minutes, feedback, advice, and goal-setting. Most

also include further assistance and follow-up. Multicontact interventions for patients ranging widely in

age (12-75 years) are shown to reduce mean alcohol

consumption by 3 to 9 drinks per week, with effects

lasting up to 6 to 12 months after the intervention.

They can be delivered wholly or in part in the

primary care setting, and by one or more members

of the health care team, including physician and

non-physician practitioners. Resources that help

clinicians deliver effective interventions include

brief provider training or access to specially trained

primary care practitioners or health educators, and

the presence of office-level systems supports

(prompts, reminders, counseling algorithms, and

patient education materials).

n Primary care screening and behavioral counseling

interventions for alcohol misuse can be described

with reference to the 5-As behavioral counseling

Alcohol Misuse

133
framework: assess alcohol consumption with a brief

screening tool followed by clinical assessment as

needed; advise patients to reduce alcohol

consumption to moderate levels; agree on individual

goals for reducing alcohol use or abstinence (if

indicated); assist patients with acquiring the

motivations, self-help skills, or supports needed for

behavior change; and arrange follow-up support and

repeated counseling, including referring dependent

drinkers for specialty treatment. Common practices

that complement this framework include

motivational interviewing, the 5 Rs used to treat

tobacco use, and assessing readiness to change.

n The optimal interval for screening and intervention is

unknown. Patients with past alcohol problems,

young adults, and other high-risk groups (e.g.,

smokers) may benefit most from frequent screening.

n All pregnant women and women contemplating

pregnancy should be informed of the harmful effects

of alcohol on the fetus. Safe levels of alcohol

consumption during pregnancy are not known;

therefore, pregnant women are advised to abstain

from drinking alcohol. More research into the

efficacy of primary care screening and behavioral

intervention for alcohol misuse among pregnant

women is needed.

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Alcohol Misuse
n The benefits of behavioral intervention for

preventing or reducing alcohol misuse in

adolescents are not known. The CRAFFT

questionnaire was recently validated for screening

adolescents for substance abuse in the primary care

setting. The benefits of screening this population

will need to be evaluated as more effective

interventions become available in the primary care

setting.

This USPSTF recommendation was first published in:

Ann Intern Med. 2004; 140:555-557.

135

Alcohol Misuse
136

Screening for Depression in Adults

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends screening adults for

depression when staff-assisted depression care

supports are in place to assure accurate diagnosis,

effective treatment, and followup. Grade: B

Recommendation.

The USPSTF recommends against routinely

screening adults for depression when staff-assisted

depression care supports are not in place. There

may be considerations that support screening for

depression in an individual patient. Grade: C

Recommendation.

Clinical Considerations

n This recommendation statement applies to

nonpregnant adults, including older adults. It does

not apply to children and adolescents, who are

considered a separate population.

n Individuals at increased risk for depression are

considered at risk throughout their lifetime. Groups

at increased risk include persons with other

psychiatric disorders, including substance misuse;

persons with a family history of depression; persons

with chronic medical diseases; and persons who are

unemployed or of lower socioeconomic status. Also,

women are at increased risk compared with men.

Significant depressive symptoms are associated with
Screening for Depression in Adults

137

common life events in older adults, including

medical illness, cognitive decline, bereavement, and

institutional placement in residential or inpatient

settings. However, the presence of risk factors alone

cannot distinguish depressed patients from

nondepressed patients.

n The USPSTF reviewed evidence about the accuracy

of screening instruments in identifying depressed

adults in 2002. Many formal screening tools are

available, including instruments designed

specifically for older adults. Asking 2 simple

questions about mood and anhedonia (“Over the

past 2 weeks, have you felt down, depressed, or

hopeless?” and “Over the past 2 weeks, have you

felt little interest or pleasure in doing things?”) may

be as effective as using more formal instruments.

There is little evidence to recommend 1 screening

method over another; therefore, clinicians may

choose the method most consistent with their

personal preference, the patient population being

served, and the practice setting.

All positive screening tests should trigger full

diagnostic interviews that use standard diagnostic

criteria (that is, those from the updated Diagnostic

and Statistical Manual of Mental Disorders, Fourth

Edition) to determine the presence or absence of

specific depressive disorders, such as MDD or

dysthymia. The severity of depression and comorbid

psychological problems (for example, anxiety, panic

attacks, or substance abuse) should be addressed.
n The reviews of evidence on which this

recommendation is based cover treatment of adults

with antidepressants or psychotherapy and updated

evidence on the efficacy of depression treatment in

older adults. Treatment may include antidepressants

or specific psychotherapeutic approaches (for

example, cognitive behavioral therapy or brief

psychosocial counseling) alone or in combination.

Both are effective in treating adults and older

adults.

In treating patients aged 18 to 29 years, clinicians

may want to select a psychotherapeutic approach or

medications other than SSRIs because of the

increased risk for suicidal behavior associated with

the use of SSRIs. Similarly, for adults 65 years or

older, clinicians may want to select a

psychotherapeutic approach or medications other

than SSRIs because of the increased risk for UGI

bleeding associated with the use of SSRIs. In

addition, the concurrent use of SSRIs with a

nonsteroidal anti-inflammatory drug (NSAID) or

low-dose aspirin increases the risk for UGI bleeding

in adults (aged 40 to 79 years), although the

increase in risk is less with aspirin. The risk for UGI

bleeding is greater for medications that feature a

moderate to high degree of serotonin reuptake

inhibition.

n “Staff-assisted depression care supports” refers to

clinical staff that assist the primary care clinician by

providing some direct depression care, such as care

138

Screening for Depression in Adults
support or coordination, case management, or

mental health treatment.

In the available evidence, the lowest effective level

of staff-assisted depression care supports consisted

of a screening nurse who advised resident physicians

of positive screening results and provided a protocol

that facilitated referral to behavioral treatment. At

the highest level, staff-assisted depression care

supports included screening; institutional monetary

commitment; staff and clinician training (1- or 2-

day workshops); clinician manuals; monthly

training lectures; academic detailing; many materials

for clinicians, staff, and patients; an initial visit with

a nurse specialist for assessment, education, and

discussion of patient preferences and goals; a visit

with a trained nurse specialist for follow-up

assessment and ongoing support for adherence to

medication for those prescribed antidepressant

medications; a visit with a trained therapist for

cognitive behavioral therapy; and a reduced copay

for patients referred for psychotherapy. In a

successful study designed for practices without

ready access to mental health specialty care, office

staff recruited, screened, and enrolled participants

who screened positive for depression before a clinic

visit. If the physician confirmed the depression

diagnosis, the participant was scheduled for a return

visit with the physician and to meet with the nurse

specialist in 1 week. The nurse specialist reassessed

the patient’s level of depression, discussed treatment

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Screening for Depression in Adults
Screening for Depression in Adults

140

options and preferences, and asked the participant

to complete a homework assignment. Participants

completed up to 8 additional sessions that followed

the same pattern, either by phone or in person.

Multidisciplinary team-based primary care that

includes self-management support and care

coordination has been shown to be effective in

management of depression. These components of

primary care are detailed in recent

recommendations from the Task Force on

Community Preventive Services. It recommends

collaborative care for treatment of adults 18 years or

older with major depression on the basis of strong

evidence of effectiveness in improving short-term

treatment outcomes. As defined, collaborative care

and disease management of depressive disorders

includes a systematic, multicomponent, team-based

approach that “strengthens and supports self-care,

while assuring that effective medical, preventive and

health maintenance interventions take place” to

improve the quality and outcome of patient care for

treatment of major depressive disorders.

n The optimum interval for screening for depression

is unknown. Recurrent screening may be most

productive in patients with a history of depression,

unexplained somatic symptoms, comorbid

psychological conditions (for example, panic

disorder or generalized anxiety), substance abuse, or

chronic pain.
Screening for Depression in Adults

141

n The Task Force on Community Preventive Services

also has made several recommendations about

depression care in older adults. It recommends

clinic-based depression care management to reduce

depression in older adults on the basis of sufficient

evidence and home-based depression care

management on the basis of strong evidence. The

Task Force on Community Preventive Services

found insufficient evidence to determine the

effectiveness of community-based exercise

interventions for reducing depression in older

adults.

The Task Force on Community Preventive Services

makes recommendations on population-based

interventions appropriate for use by communities

and health care systems to promote health and to

prevent disease, injury, disability, and premature

death. More information about the Task Force on

Community Preventive Services and its

recommendations on depression interventions is

available on their Web site

(http://www.thecommunityguide.org).

n The USPSTF recently updated its recommendation

on screening for depression in children and

adolescents. The USPSTF recommends screening

adolescents (aged 12 to 18 years) for MDD when

systems are in place to assure accurate diagnosis,

psychotherapy (cognitive behavioral or

interpersonal), and follow-up (Grade B

recommendation). In addition, the USPSTF
concluded that the current evidence is insufficient

to assess the balance of benefits and harms of

screening of children (aged 7 to 11 years) for MDD

(I statement).

In 2004, the USPSTF concluded that the evidence

is insufficient to recommend for or against routine

screening by primary care clinicians to detect

suicide risk in the general population (I statement).

At that time, the USPSTF found no evidence that

screening for suicide risk reduces suicide attempts or

mortality. The USPSTF also found limited evidence

on the accuracy of screening tools to identify suicide

risk in the primary care setting, including tools to

identify those at high risk, and found no evidence

that directly addressed the harms of screening and

treatment of suicide risk. In addition, the USPSTF

found insufficient evidence that treatment of those

at high risk reduces suicide attempts or mortality.

For the full recommendation statements and

evidence reviews, please go to the USPSTF Web site

(http://www.USPreventiveServicesTaskForce.org).

This USPSTF recommendation was first published in:

Ann Intern Med. 2009; 151:784-792.

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Screening for Depression in Adults
Screening for Illicit Drug Use

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the current evidence is

insufficient to assess the balance of benefits and

harms of screening adolescents, adults, and

pregnant women for illicit drug use. Grade: I

Statement.

Clinical Considerations

n While the rate of illicit drug use in the U.S. is

highest between the ages of 18 to 20 years, more

than 10% of adolescents aged 12 to 17 are known

to use illicit drugs. The percentage of adults who

regularly use illicit drugs decreases steadily with age.

About 5% of pregnant women report using illicit

drugs within the past month.

n Marijuana is the most commonly used illicit drug in

the United State, with about 6% of the population

age 12 and older admitting to use within the past

month. While cocaine is the second most

commonly used illicit drug, it is used by less than

1% of the population. Only a small minority of

Americans use hallucinogens, inhalants, heroin, or

illicitly manufactured methamphetamine, although

the potential for abuse of or dependence on these

substances is high. Illicit (non-medical) use of

prescription-type drugs, categorized as pain

relievers, tranquilizers, stimulants, and sedatives, is a

growing health problem in the U.S.

143
Screening for Illicit Drug Use

144

n While clinicians should be alert to the signs and

symptoms of illicit drug use in patients, the added

benefits of screening asymptomatic patients in

primary care practice remains unclear. Toxicologic

tests of blood or urine can provide objective

evidence of drug use, but such tests do not

distinguish between occasional users and those who

are impaired by drug use. A few brief, standardized

questionnaires have been shown to be valid and

reliable in screening adolescent and adult patients

for drug use/misuse. However, the clinical utility of

these questionnaires is uncertain. The reported

positive predictive values are variable and at best

83% when the questionnaires are applied in a

general medical clinic. Moreover, the feasibility of

routinely incorporating the questionnaires into busy

primary care practices has yet to be assessed. The

validity, reliability, and clinical utility of

standardized questionnaires in screening for illicit

drug use during pregnancy have not been

adequately evaluated.

n Although drug-specific pharmacotherapy (e.g.,

buprenorphine for opiate abuse) and/or behavioral

interventions (e.g., brief motivational counseling for

cannabis misuse) have been proven effective in

reducing illicit drug use in the short term, the

longer-term effects of treatment on morbidity and

mortality have been inadequately evaluated.

Moreover, these treatments have been studied

almost exclusively in individuals who have already

developed medical, social, or legal problems due to
Screening for Illicit Drug Use

145

drug use, and their effectiveness in individuals

identified through screening remains unclear. In all

but one trial, treatment was delivered outside the

primary care setting, often in specialized treatment

facilities. More evidence is needed on the

effectiveness of office-based treatments for illicit

drug use/dependence.

n While interventions to prevent or reduce illicit drug

use have been proposed for use in schools and sites

of employment, evidence assessing preventive

measures delivered in settings other than primary

care practice was outside the scope of the USPSTF

review.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. January 2008. http://www.USPreventiveServicesTask

Force.org.
Screening for Suicide Risk

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend for or against routine

screening by primary care clinicians to detect

suicide risk in the general population. Grade: I

Statement.

Clinical Considerations

n The strongest risk factors for attempted suicide

include mood disorders or other mental disorders,

comorbid substance abuse disorders, history of

deliberate self-harm (DSH), and a history of suicide

attempts. DSH refers to intentionally initiated acts

of self-harm with a non-fatal outcome (including

self-poisoning and self-injury). Suicide risk is

assessed along a continuum ranging from suicidal

ideation alone (relatively less severe) to suicidal

ideation with a plan (more severe). Suicidal ideation

with a specific plan of action is associated with a

significant risk for attempted suicide.

n Screening instruments are commonly used in

specialty clinics and mental health settings. The test

characteristics of most commonly-used screening

instruments (Scale for Suicide Ideation [SSI], Scale

for Suicide Ideation-Worst [SSI-W], and the

Suicidal Ideation Questionnaire [SIQ)]) have not

146
Screening for Suicide Risk

147

been validated to assess suicide risk in primary care

settings. There has been limited testing of the

Symptom-Driven Diagnostic System for Primary

Care (SDDS-PC) screening instrument in a

primary care setting.

This USPSTF recommendation was first published in:

Ann Intern Med. 2004; 140:820-821.
Counseling and Interventions to Prevent

Tobacco Use and Tobacco-Caused

Disease in Adults and Pregnant Women

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends that clinicians ask all

adults about tobacco use and provide tobacco

cessation interventions for those who use tobacco

products. Grade: A Recommendation.

The USPSTF recommends that clinicians ask all

pregnant women about tobacco use and provide

augmented, pregnancy-tailored counseling for

those who smoke. Grade: A Recommendation.

Clinical Considerations

n This recommendation applies to adults 18 years or

older and all pregnant women regardless of age. The

USPSTF plans to issue a separate recommendation

statement about counseling to prevent tobacco use

in nonpregnant adolescents and children.

n Various primary care clinicians may deliver effective

interventions. There is a dose-response relationship

between quite rates and the intensity of counseling

(that is, more or longer sessions improve quit rates).

Quit rates seem to plateau after 90 minutes of total

counseling contact time. Helpful components of

counseling include problem-solving guidance for

smokers (to help them develop a plan to quit and

overcome common barriers to quitting) and the

148
provision of social support as part of treatment.

Complementary practices that improve cessation

rates include motivational interviewing, assessing

readiness to change, offering more intensive

counseling or referrals, and using telephone “quit

lines.”

n Combination therapy with counseling and

medications is more effective at increasing cessation

rates than either component alone. Pharmacotherapy

approved by the U.S. Food and Drug

Administration and identified as effective for treating

tobacco dependence in nonpregnant adults includes

several forms of nicotine replacement therapy (gum,

lozenge, transdermal patch, inhaler, and nasal spray),

sustained-release bupropion, and varenicline.

n Detailed reviews and recommendations about

clinical interventions for tobacco cessation are

available in the U.S. Public Health Service Clinical

Practice Guideline “Treating Tobacco Use and

Dependence: 2008 Update” (available at

http://www.surgeongeneral.gov/tobacco).

Tobacco-related recommendations from the Centers

for Disease Control and Prevention’s Guide to

Community Preventive Services are available at:

http://www.thecommunityguide.org/tobacco/

index.html.

This USPSTF recommendation was first published in:

Ann Intern Med. 2009; 150:551-555.

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Tobacco Use and Tobacco-Caused Disease
150
151

Metabolic, Nutritional, and

Endocrine Conditions

Behavioral Counseling in Primary Care

to Promote a Healthy Diet

NOTE: The USPSTF was updating its

recommendation on this topic during publication

of The Guide to Clinical Preventive Services 2010-

2011. For the most recent recommendation, please

visit the USPSTF Web site at:

http://www.USPreventiveServicesTaskForce.org or

the USPSTF’s Electronic Preventive Services

Selector (ePSS) at http://epss.ahrq.gov. You can

search the ePSS for recommendations by patient

age, sex, and pregnancy status, and you can

download the recommendations as well as receive

automatic updates to your PDA.
152

Folic Acid to Prevent Neural Tube

Defects

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends that all women planning

or capable of pregnancy take a daily supplement

containing 0.4 to 0.8 mg (400 to 800 μg) of folic

acid. Grade: A Recommendation.

Clinical Considerations

n This recommendation statement applies to women

who are planning or capable of pregnancy, but it

does not apply to women who have had a previous

pregnancy affected by neural tube defects or women

taking certain antiseizure medicines. Most

organizations recommend that these women take

higher doses of folic acid.

n The use of certain antiseizure medicines and a

personal or family history of neural tube defects are

well-established risk factors. Other reported risk

factors include mutations in folate-related enzymes,

maternal diabetes, and obesity.

n Most studies indicate the need to start folic acid

supplementation at least 1 month before conception

and to continue daily supplements through the first

2 to 3 months of pregnancy. Studies also indicate

that 50% of pregnancies in the United States are

unplanned, and clinicians should therefore advise all

women who are capable of pregnancy to take folic

acid supplements.
Folic Acid

n Good evidence from randomized trials in settings

without fortification of food suggests that a

multivitamin with 0.8 mg (800 μg) of folic acid

reduces the risk for neural tube defects.

Observational studies done before fortification

report a reduction of neural tube defects in women

taking a supplement with 0.4 mg (400 μg) of folic

acid (the generally available dose). Evidence

indicates that most women in the United States are

not ingesting fortified foods at a level thought to

provide optimal benefit. In a setting in which food

is fortified with folic acid, the effective amount of

additional folic acid supplementation is unclear.

This USPSTF recommendation was first published in:

Ann Intern Med 2009; 150:626-631.

153
Clinical Considerations

n This recommendation applies to asymptomatic

persons. This recommendation does not include

individuals with signs or symptoms that would

include hereditary hemochromatosis in the

differential diagnosis. Furthermore, it does not

include individuals with a family history of

clinically detected or screening-detected probands

for hereditary hemochromatosis.

n Clinically important disease due to hereditary

hemochromatosis appears to be rare. Even among

individuals with mutations on the hemochromatosis

(HFE) gene, it appears that only a small subset will

develop symptoms of hemochromatosis. An even

smaller proportion of these individuals will develop

advanced stages of clinical disease.

n Clinically recognized hereditary hemochromatosis is

primarily associated with the HFE mutation

C282Y. Although this is a relatively common

mutation in the U.S. population, great racial and

ethnic variations exist. The frequency of

homozygosity is 4.4 per 1000 among white persons,

Screening for Hemochromatosis

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against routine genetic

screening for hereditary hemochromatosis in the

asymptomatic general population. Grade: D

Recommendation.

154
Screening for Hemochromatosis

155

with much lower frequencies among Hispanic

persons (0.27 per 1000), black persons (0.14 per

1000), and Asian-American persons (<0.001 per

1000). Screening of family members of probands

identifies the highest prevalence of undetected

C282Y homozygotes (23 percent of all family

members tested), particularly among siblings (33

percent homozygosity).

n The natural history of disease due to hereditary

hemochromatosis is not well understood but

appears to vary considerably among individuals.

Clinically recognized hereditary hemochromatosis is

about twice as common in men as in women. Iron

accumulation and disease expression are modified

by environmental factors, including blood loss or

donation, alcohol use, diet, and infections such as

viral hepatitis.

n Among C282Y homozygotes newly identified in the

general population by genotypic screening, 6

percent of those undergoing further evaluation had

cirrhosis (representing 1.4 percent of all newly

screening-identified C282Y homozygotes).

Cirrhosis is a serious, late-stage disease

development, and its prevention would be a major

goal of screening and treatment.

n Individuals with a family member, especially a

sibling, who is known to have hereditary

hemochromatosis may be more likely to develop

symptoms. These individuals should be counseled

regarding genotyping, with further diagnostic

testing as warranted as part of case-finding.
n In addition to genotyping, more common

laboratory testing can sometimes identify iron

overload. Clinical screening with these laboratory

tests, or phenotypic screening, was not included in

the evidence synthesis on which this

recommendation is based. Genotyping primarily

focuses on the identification of the C282Y

mutation on HFE. While other mutations exist,

C282Y homozygosity is most commonly associated

with clinical manifestations. Identifying an

individual with the genotypic predisposition does

not accurately predict the future risk for disease

manifestation.

n Therapeutic phlebotomy is the primary treatment

for hemochromatosis. Treated individuals report

inconsistent improvement of their signs and

symptoms. It is uncertain whether cirrhosis at

diagnosis confers a worse prognosis based on the

potential lack of reversibility of liver damage.

Recent research reports survival rates in treated

individuals with or without cirrhosis that are similar

to rates in healthy controls. The degree to which

clinically important manifestations can be averted

remains uncertain, as does the optimal time for

early treatment.

This USPSTF recommendation was first published in:

Ann Intern Med. 2006; 145:204-208.

156

Screening for Hemochromatosis
Hormone Therapy for the Prevention of

Chronic Conditions in Postmenopausal

Women

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends against the routine use of

combined estrogen and progestin for the

prevention of chronic conditions in

postmenopausal women. Grade: D

Recommendation.

The USPSTF recommends against the routine

use of unopposed estrogen for the prevention of

chronic conditions in postmenopausal women who

have had a hysterectomy. Grade: D

Recommendation.

Clinical Considerations

n The balance of benefits and harms for a woman will

be influenced by her personal preferences, her risks

for specific chronic diseases, and the presence of

menopausal symptoms. A shared decisionmaking

approach to preventing chronic diseases in

perimenopausal and postmenopausal women

involves consideration of individual risk factors and

preferences in selecting effective interventions for

reducing the risks for fracture, heart disease, and

cancer. See other USPSTF recommendations for

prevention of chronic diseases (screening for

osteoporosis, high blood pressure, lipid disorders,

157
breast cancer, and colorectal cancer; and counseling

to prevent tobacco use) available at:

www.USPreventiveServicesTaskForce.org.

n The USPSTF did not consider the use of hormone

therapy for the management of menopausal

symptoms, which is the subject of

recommendations by other expert groups. Women

and their clinicians should discuss the balance of

risks and benefits before deciding to initiate or

continue hormone therapy for menopausal

symptoms. For example, for combined estrogen and

progestin, some risks (such as the risks for venous

thromboembolism, coronary heart disease [CHD],

and stroke) arise within the first 1 to 2 years of

therapy, and other risks (such as the risk for breast

cancer) appear to increase with longer-term

hormone therapy. The populations of women using

hormone therapy for symptom relief may differ

from those who would use hormone therapy for

prevention of chronic disease (e.g., age differences).

Other expert groups have recommended that

women who decide to take hormone therapy to

relieve menopausal symptoms use the lowest

effective dose for the shortest possible time.

n Although estrogen alone or in combination with

progestin reduces the risk for fractures in women,

other effective medications (e.g., bisphosphonates

and calcitonin) are available for treating women

158

Hormone Therapy
Hormone Therapy

159

with low bone density to prevent fractures. The

role of chemopreventive agents in preventing

fractures in women without low bone density is

unclear. The USPSTF addressed screening for

osteoporosis in postmenopausal women in 2002.

n Unopposed estrogen increases the risk for

endometrial cancer in women who have an intact

uterus. Clinicians should use a shared decisionmaking approach when discussing the possibility of

using unopposed estrogen in women who have not

had a hysterectomy.

This USPSTF recommendation was first published in:

Ann Intern Med. 2005; 142:855-860.
160

Screening for Iron Deficiency Anemia—

Including Iron Supplementation for

Children and Pregnant Women

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) concludes that evidence is insufficient

to recommend for or against routine screening for

iron deficiency anemia in asymptomatic children

aged 6 to 12 months. Grade: I Statement.

The USPSTF recommends routine screening for

iron deficiency anemia in asymptomatic pregnant

women. Grade: B Recommendation.

The USPSTF recommends routine iron

supplementation for asymptomatic children aged 6

to 12 months who are at increased risk for iron

deficiency anemia (see Clinical Considerations for

a discussion of increased risk). Grade: B

Recommendation.

The USPSTF concludes that evidence is

insufficient to recommend for or against routine

iron supplementation for asymptomatic children

aged 6 to 12 months who are at average risk for

iron deficiency anemia. Grade: I Statement.

The USPSTF concludes that evidence is

insufficient to recommend for or against routine

iron supplementation for non-anemic pregnant

women. Grade: I Statement.
Screening for Iron Deficiency Anemia

161

Clinical Considerations

n These USPSTF recommendations address screening

for iron deficiency anemia and iron

supplementation in children aged 6 to 12 months

who are at increased risk and average risk, in

asymptomatic pregnant women, and in non-anemic

pregnant women. Infants younger than 6 months of

age, older children, non-pregnant women, and men

are not addressed.

n Iron deficiency anemia can be defined as iron

deficiency (abnormal values for serum ferritin,

transferrin saturation, and free erythrocyte

protoporphyrin) with a low hemoglobin or

hematocrit value. Iron deficiency is much more

common than iron deficiency anemia and is part of

a continuum that ranges from iron depletion to

iron deficiency anemia. Many of the negative health

outcomes of iron deficiency are associated with its

extreme manifestation, iron deficiency anemia. Iron

deficiency has also been associated with negative

neurodevelopmental outcomes in children.

n Other causes of anemia vary by population and

include other nutritional deficiencies, abnormal

hemoglobin (e.g., thalassemia), enzyme defects, and

anemia associated with acute and chronic infections.

n In the U.S., race, income, education, and other

socioeconomic factors are associated with iron

deficiency and iron deficiency anemia. Individuals

considered to be at high risk for iron deficiency

include adult females, recent immigrants, and

among adolescent females, fad dieters, and those
Screening for Iron Deficiency Anemia

162

who are obese. Premature and low birth weight

infants are also at increased risk for iron deficiency.

n Venous hemoglobin is more accurate than capillary

hemoglobin for identifying anemia. Ferritin has the

highest sensitivity and specificity for diagnosing

iron deficiency in anemic patients.

n Iron deficiency anemia is usually treated with oral

iron preparations. The likelihood that iron

deficiency anemia identified by screening will

respond to treatment is unclear because many

families do not adhere to treatment and because the

rate of spontaneous resolution is high. 97 percent of

infant formula sold in the U.S. is iron-fortified.

Substantial reductions in the incidence of iron

deficiency and iron deficiency anemia have been

demonstrated in healthy infants fed iron-fortified

formula or iron-fortified cereal, compared with

infants fed cow’s milk or unfortified formula.

n Iron supplements accounted for 30 percent of fatal

pediatric pharmaceutical overdoses occurring

between 1983 and 1990, and iron poisoning has

been observed even in the context of controlled

trials in which parents were instructed in the safe

storage and use of iron products. A reduction in

deaths of children due to iron overdose was

observed when unit-dose packaging was required

between 1998 and 2002; this requirement was

overturned by the courts in 2003.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. May 2006. http://www.USPreventiveServicesTask

Force.org.
163

Screening for Obesity in Adults

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends that clinicians screen all

adult patients for obesity and offer intensive

counseling and behavioral interventions to

promote sustained weight loss for obese adults.

Grade: B Recommendation.

The USPSTF concludes that the evidence is

insufficient to recommend for or against the use of

moderate- or low-intensity counseling together

with behavioral interventions to promote sustained

weight loss in obese adults. Grade: I Statement.

The USPSTF concludes that the evidence is

insufficient to recommend for or against the use of

counseling of any intensity and behavioral

interventions to promote sustained weight loss in

overweight adults. Grade: I Statement.

Clinical Considerations

n A number of techniques, such as bioelectrical

impedance, dual-energy x-ray absorptiometry, and

total body water can measure body fat, but it is

impractical to use them routinely. Body mass index
Screening for Obesity in Adults

164

(BMI), which is simply weight adjusted for height,

is a more practical and widely-used method to

screen for obesity. Increased BMI is associated with

an increase in adverse health effects. Central

adiposity increases the risk for cardiovascular and

other diseases independent of obesity. Clinicians

may use the waist circumference as a measure of

central adiposity. Men with waist circumferences

greater than 102 cm (> 40 inches) and women with

waist circumferences greater than 88 cm (> 35

inches) are at increased risk for cardiovascular

disease. The waist circumference thresholds are not

reliable for patients with a BMI greater than 35.

n Expert committees have issued guidelines defining

overweight and obesity based on BMI. Persons with

a BMI between 25 and 29.9 are overweight and

those with a BMI of 30 and above are obese. There

are 3 classes of obesity: class I (BMI 30-34.9), class

II (BMI 35-39.9), and class III (BMI 40 and

above). BMI is calculated either as weight in

pounds divided by height in inches squared

multiplied by 703, or as weight in kilograms

divided by height in meters squared. The National

Institutes of Health (NIH) provides a BMI

calculator at www.nhlbisupport.com/bmi/ and a

table at www.nhlbi.nih.gov/guidelines/obesity/

bmi_tbl.htm.

n The most effective interventions combine nutrition

education and diet and exercise counseling with

behavioral strategies to help patients acquire the

skills and supports needed to change eating patterns
Screening for Obesity in Adults

and to become physically active. The 5-A

framework (Assess, Advise, Agree, Assist, and

Arrange) has been used in behavioral counseling

interventions such as smoking cessation and may be

a useful tool to help clinicians guide interventions

for weight loss. Initial interventions paired with

maintenance interventions help ensure that weight

loss will be sustained over time.

n It is advisable to refer obese patients to programs

that offer intensive counseling and behavioral

interventions for optimal weight loss. The USPSTF

defined intensity of counseling by the frequency of

the intervention. A high-intensity intervention is

more than 1 person-to-person (individual or group)

session per month for at least the first 3 months of

the intervention. A medium-intensity intervention

is a monthly intervention, and anything less

frequent is a low-intensity intervention. There are

limited data on the best place for these

interventions to occur and on the composition of

the multidisciplinary team that should deliver highintensity interventions.

n The USPSTF concluded that the evidence on the

effectiveness of interventions with obese people may

not be generalizable to adults who are overweight

but not obese. The evidence for the effectiveness of

interventions for weight loss among overweight

adults, compared with obese adults, is limited.

n Orlistat and sibutramine, approved for weight loss

by the Food and Drug Administration, can produce

modest weight loss (2.6-4.8 kg) that can be

165
Screening for Obesity in Adults

166

sustained for at least 2 years if the medication is

continued. The adverse effects of orlistat include

fecal urgency, oily spotting, and flatulence; the

adverse effects of sibutramine include an increase in

blood pressure and heart rate. There are no data on

the long-term (longer than 2 years) benefits or

adverse effects of these drugs. Experts recommend

that pharmacological treatment of obesity be used

only as part of a program that also includes lifestyle

modification interventions, such as intensive diet

and/or exercise counseling and behavioral

interventions.

n There is fair to good evidence to suggest that

surgical interventions such as gastric bypass, vertical

banded gastroplasty, and adjustable gastric banding

can produce substantial weight loss (28 to > 40 kg)

in patients with class III obesity. Clinical guidelines

developed by the National Heart, Lung, and Blood

Institute (NHLBI) Expert Panel on the

identification, evaluation, and treatment of

overweight and obesity in adults recommend that

these procedures be reserved for patients with class

III obesity and for patients with class II obesity who

have at least 1 other obesity-related illness. The

postoperative mortality rate for these procedures is

0.2 percent. Other complications include wound

infection, re-operation, vitamin deficiency, diarrhea,

and hemorrhage. Re-operation may be necessary in

up to 25 percent of patients. Patients should receive

a psychological evaluation prior to undergoing these

procedures. The long-term health effects of surgery
Screening for Obesity in Adults

167

for obesity are not well characterized.

n The data supporting the effectiveness of

interventions to promote weight loss are derived

mostly from women, especially white women. The

effectiveness of the interventions is less well

established in other populations, including the

elderly. The USPSTF believes that, although the

data are limited, these interventions may be used

with obese men, physiologically mature older

adolescents, and diverse populations, taking into

account cultural and other individual factors.

This USPSTF recommendation was first published in:

Ann Intern Med. 2003; 139:930-932.
Behavioral Counseling in Primary Care

to Promote Physical Activity

NOTE: The USPSTF was updating its

recommendation on this topic during publication

of The Guide to Clinical Preventive Services 2010-

2011. For the most recent recommendation, please

visit the USPSTF Web site at:

http://www.USPreventiveServicesTaskForce.org or

the USPSTF’s Electronic Preventive Services

Selector (ePSS) at http://epss.ahrq.gov. You can

search the ePSS for recommendations by patient

age, sex, and pregnancy status, and you can

download the recommendations as well as receive

automatic updates to your PDA.

168
Screening for Thyroid Disease

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes the evidence is insufficient to

recommend for or against routine screening for

thyroid disease in adults. Grade: I Statement.

Clinical Considerations

n Subclinical thyroid dysfunction is defined as an

abnormal biochemical measurement of thyroid

hormones without any specific clinical signs or

symptoms of thyroid disease and no history of

thyroid dysfunction or therapy. This includes

individuals who have mildly elevated TSH and

normal thyroxine (T4) and triiodothyronine (T3)

levels (subclinical hypothyroidism), or low TSH and

normal T4 and T3 levels (subclinical

hyperthyroidism). Individuals with symptoms of

thyroid dysfunction, or those with a history of

thyroid disease or treatment, are excluded from this

definition and are not the subject of these

recommendations.

n When used to confirm suspected thyroid disease in

patients referred to a specialty endocrine clinic,

TSH has a high sensitivity (98%) and specificity

169
Screening for Thyroid Disease

170

(92%). When used for screening primary care

populations, the positive predictive value (PPV) of

TSH in detecting thyroid disease is low; further, the

interpretation of a positive test result is often

complicated by an underlying illness or by frailty of

the individual. In general, values for serum TSH

below 0.1 mU/L are considered low and values

above 6.5 mU/L are considered elevated.

n Clinicians should be aware of subtle signs of thyroid

dysfunction, particularly among those at high risk.

People at higher risk for thyroid dysfunction include

the elderly, post-partum women, those with high

levels of radiation exposure (>20 mGy), and patients

with Down syndrome. Evaluating for symptoms of

hypothyroidism is difficult in patients with Down

syndrome because some symptoms and signs (e.g.,

slow speech, thick tongue, and slow mentation) are

typical findings in both conditions.

n Subclinical hyperthyroidism has been associated with

atrial fibrillation, dementia, and, less clearly, with

osteoporosis. However, progression from subclinical

to clinical disease in patients without a history of

thyroid disease is not clearly established.

n Subclinical hypothyroidism is associated with poor

obstetric outcomes and poor cognitive development

in children. Evidence for dyslipidemia,

atherosclerosis, and decreased quality of life in adults

with subclinical hypothyroidism in the general

population is inconsistent and less convincing.

This USPSTF recommendation was first published in:

Ann Intern Med. 2004; 140(2)125-127.
171

Screening for Type 2 Diabetes Mellitus

in Adults

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for type 2

diabetes in asymptomatic adults with sustained

blood pressure (either treated or untreated) greater

than 135/80 mm Hg. Grade: B Recommendation.

The USPSTF concludes that the current

evidence is insufficient to assess the balance of

benefits and harms of screening for type 2 diabetes

in asymptomatic adults with blood pressure of

135/80 mm Hg or lower. Grade: I Statement.

Clinical Considerations

n This recommendation concerns adults without

symptoms of diabetes or evidence of possible

diabetes complications. Symptoms of diabetes

include polyuria, polydipsia, and polyphagia.

Possible diabetes complications include nonhealing

ulcers or infections and established vascular disease

(for example, coronary artery disease, stroke, and

peripheral artery disease). Persons with these

symptoms or conditions should be tested for

diabetes.

n In persons with blood pressure of 135/80 mm Hg

or lower, screening may be considered on an

individual basis if knowledge of diabetes status

would help inform decisions about coronary heart
Type 2 Diabetes Mellitus

172

disease (CHD) prevention strategies, including

assessment of CHD risk and subsequent

consideration of lipid-lowering agents or aspirin.

For example, consider a patient for whom lipidlowering treatment would be recommended if his or

her 10-year CHD risk was 20% or greater. If the

patient’s calculated risk was 17% without diabetes

and greater than 20% with diabetes, then screening

for diabetes would be useful in determining lipid

treatment. However, if the calculated risk was 10%

without diabetes and 15% with diabetes, then the

screening test result would have no effect on the

decision whether to use lipid-lowering treatment.

n Blood pressure is an important predictor of

complications of cardiovascular disease (CVD)

(including CHD and stroke) in persons with type 2

diabetes mellitus and should be measured as the

first step in applying this recommendation. The

examination of global CHD and stroke risk allows

the clinician to determine how aggressive treatment

for CVD risk factors needs to be. In making this

assessment, clinicians should use any of several

validated CHD risk assessment calculators, such as

the calculator based on Framingham Heart Study

data (available at http://hp2010.nhlbihin.net/

atpiii.calculator.asp).

n Three tests have been used to screen for diabetes:

fasting plasma glucose, 2-hour postload plasma

glucose, and hemoglobin A1c. Each has advantages

and disadvantages. The American Diabetes

Association has recommended the fasting plasma
Type 2 Diabetes Mellitus

173

glucose test for screening because it is easier and

faster to perform, more convenient and acceptable

to patients, and less expensive than other screening

tests. The fasting plasma glucose test has more

reproducible results than does the 2-hour postload

plasma glucose test, has less intraindividual

variation, and has similar predictive value for

development of microvascular complications of

diabetes. The American Diabetes Association

defines diabetes as a fasting plasma glucose level of

126 mg/dL or greater and recommends

confirmation with a repeated screening test on a

separate day, especially for people with borderline

results.

n Blood pressure targets should be lower for persons

who have type 2 diabetes mellitus than for those

who do not. Lower blood pressure targets for

persons with diabetes and high blood pressure

reduce CVD events compared with higher targets.

Attention to other risk factors for CVD, such as

physical inactivity, lipid levels, diet, and obesity, is

also important, both to decrease risk for CHD and

to improve glucose control.

n The optimal screening interval is not known. The

American Diabetes Association, on the basis of

expert opinion, recommends a 3-year interval.

n There is no evidence of benefit in health outcomes

from screening for impaired glucose tolerance

(IGT) or impaired fasting glucose (IFG). However,

intensive programs of lifestyle modification (diet,

exercise, and behavior) do reduce the incidence of
diabetes. Regardless of whether the clinician and

patient decide to screen for diabetes, people should

eat a healthful diet, be active, and maintain a healthy

weight—these behaviors have other benefits in

addition to preventing or forestalling type 2 diabetes.

The USPSTF recommends intensive interventions

for obese persons who desire to lose weight.

Population-based approaches to increasing physical

activity and reducing obesity, as recommended by

the Task Force on Community Preventive Services,

should be supported.

n Evidence and USPSTF recommendations on blood

pressure, diet, physical activity, and obesity are

available at http://www.USPreventiveServices

TaskForce.org. The reviews and recommendations

for the Task Force on Community Preventive

Services may be found at

http://www.thecommunityguide.org.

This USPSTF recommendation was first published in:

Ann Intern Med. 2008; 148:846-854.

174

Type 2 Diabetes Mellitus
Musculoskeletal Conditions

Screening for Osteoporosis

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends that women aged 65 and

older be screened routinely for osteoporosis. The

USPSTF recommends that routine screening begin

at age 60 for women at increased risk for

osteoporotic fractures (see Clinical Considerations

for discussion of women at increased risk). Grade:

B Recommendation.

The USPSTF makes no recommendation for or

against routine osteoporosis screening in

postmenopausal women who are younger than 60

or in women aged 60-64 who are not at increased

risk for osteoporotic fractures. Grade: C

Recommendation.

Clinical Considerations

n Modeling analysis suggests that the absolute benefits

of screening for osteoporosis among women aged

175
Screening for Osteoporosis

176

60-64 who are at increased risk for osteoporosis and

fracture are comparable to those of routine

screening in older women. The exact risk factors

that should trigger screening in this age group are

difficult to specify based on evidence. Lower body

weight (weight < 70 kg ) is the single best predictor

of low bone mineral density. Low weight and no

current use of estrogen therapy are incorporated

with age into the 3-item Osteoporosis Risk

Assessment Instrument (ORAI). There is less

evidence to support the use of other individual risk

factors (for example, smoking, weight loss, family

history, decreased physical activity, alcohol or

caffeine use, or low calcium and vitamin D intake)

as a basis for identifying high-risk women younger

than 65. At any given age, African-American

women on average have higher bone mineral

density (BMD) than white women and are thus less

likely to benefit from screening.

n Among different bone measurement tests performed

at various anatomical sites, bone density measured

at the femoral neck by dual-energy x-ray

absorptiometry (DXA) is the best predictor of hip

fracture and is comparable to forearm

measurements for predicting fractures at other sites.

Other technologies for measuring peripheral sites

include quantitative ultrasonography (QUS),

radiographic absorptiometry, single energy x-ray

absorptiometry, peripheral dual-energy x-ray
Screening for Osteoporosis

177

absorptiometry, and peripheral quantitative

computed tomography. Recent data suggest that

peripheral bone density testing in the primary care

setting can also identify postmenopausal women

who have a higher risk for fracture over the short

term (1 year). Further research is needed to

determine the accuracy of peripheral bone density

testing in comparison with dual-energy x-ray

absorptiometry (DXA). The likelihood of being

diagnosed with osteoporosis varies greatly

depending on the site and type of bone

measurement test, the number of sites tested, the

brand of densitometer used, and the relevance of

the reference range.

n Estimates of the benefits of detecting and treating

osteoporosis are based largely on studies of

bisphosphonates. Some women, however, may

prefer other treatment options (for example,

hormone replacement therapy, selective estrogen

receptor modulators, or calcitonin) based on

personal preferences or risk factors. Clinicians

should review with patients the relative benefits and

harms of available treatment options, and

uncertainties about their efficacy and safety, to

facilitate an informed choice.

n No studies have evaluated the optimal intervals for

repeated screening. Because of limitations in the

precision of testing, a minimum of 2 years may be
Screening for Osteoporosis

178

needed to reliably measure a change in bone

mineral density; however, longer intervals may be

adequate for repeated screening to identify new

cases of osteoporosis. Yield of repeated screening

will be higher in older women, those with lower

BMD at baseline, and those with other risk factors

for fracture.

n There are no data to determine the appropriate age

to stop screening and few data on osteoporosis

treatment in women older than 85. Patients who

receive a diagnosis of osteoporosis fall outside the

context of screening but may require additional

testing for diagnostic purposes or to monitor

response to treatment.

This USPSTF recommendation was first published in:

Ann Intern Med. 2002; 137:526-528.
Clinical Considerations

n Several factors have been associated with increased

risk for preterm delivery. All of these associations

are small to moderate. These factors include, but are

not limited to, African-American race or ethnicity,

body mass index less than 20 kg/m2

, previous

preterm delivery, vaginal bleeding, a short cervix

(<2.5 cm), pelvic infection, and bacterial vaginosis.

These factors can act in isolation or in combination.

Furthermore, bacterial vaginosis in pregnancy is

more common among African-American women,

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends against screening for

bacterial vaginosis in asymptomatic pregnant

women at low risk for preterm delivery.

Grade: D Recommendation.

The USPSTF concludes that the current

evidence is insufficient to assess the balance of

benefits and harms of screening for bacterial

vaginosis in asymptomatic pregnant women at

high risk for preterm delivery. Grade: I Statement.

Obstetric and Gynecologic

Conditions

Screening for Bacterial Vaginosis in

Pregnancy

179
Screening for Bacterial Vaginosis in Pregnancy

women of low socioeconomic status, and those who

have previously delivered low-birthweight infants.

For the purpose of the current recommendation,

women were considered to be at low risk if they had

no previous preterm delivery or other risk factors for

preterm delivery (often these were nulliparous

women). Women were considered to be at high risk

if they had a previous preterm delivery.

n Bacterial vaginosis is diagnosed by using the Amsel

clinical criteria or Gram stain. With the Amsel

criteria, the clinical diagnosis is made by fulfilling 3

of 4 criteria: vaginal pH greater than 4.7, the

presence of clue cells on wet mount, thin

homogenous discharge, and amine “fishy odor”

when potassium hydroxide is added to the discharge.

n This recommendation statement addresses screening

for bacterial vaginosis in asymptomatic women.

Treatment of symptomatic cases should be based on

the clinical situation.

n Oral metronidazole and oral clindamycin, as well as

vaginal metronidazole gel or clindamycin cream, are

used to treat bacterial vaginosis. The optimal

treatment regimen for pregnant women with

bacterial vaginosis is unclear. Refer to the Centers for

Disease Control and Prevention Web site for current

treatment recommendations (http://www.cdc.gov/

std/treatment/2006/vaginal-discharge.htm#vagdis2).

This USPSTF recommendation was first published in:

Ann Intern Med. 2008; 148(3):214-219.

180
181

Primary Care Interventions to Promote

Breastfeeding

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends interventions during

pregnancy and after birth to promote and support

breastfeeding. Grade: B Recommendation.

Clinical Considerations

n This recommendation applies to pregnant women,

new mothers, and young children. In rare

circumstances involving health issues in mothers or

infants, such as HIV infection or galactosemia,

breastfeeding may be contraindicated and

interventions to promote breastfeeding may not be

appropriate. Interventions to promote and support

breastfeeding may also involve a woman’s partner,

other family members, and friends.

n The current literature does not allow assessment of

the individual aspects of multicomponent

interventions or comparative effectiveness

assessments of single-component interventions. The

promotion and support of breastfeeding may be

accomplished through interventions over the course

of pregnancy; around the time of delivery; and after

birth, while breastfeeding is under way.

Interventions may include multiple strategies, such

as formal breastfeeding education for mothers and

families, direct support of mothers during
Primary Care Interventions to Promote Breastfeeding

182

breastfeeding observations, and the training of

health professional staff about breastfeeding and

techniques for breastfeeding support. Evidence

suggests that interventions that include both

prenatal and postnatal components may be the

most effective at increasing breastfeeding duration.

Many successful programs include peer support,

prenatal breastfeeding education, or both.

This USPSTF recommendation was first published in:

Ann Intern Med 2008; 149:560-564.
183

Screening for Gestational Diabetes

Mellitus

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) concludes that the current evidence is

insufficient to assess the balance of benefits and

harms of screening for gestational diabetes mellitus

(GDM), either before or after 24 weeks gestation.

Grade: I Statement.

Clinical Considerations

n This recommendation concerns pregnant women

who have not previously been diagnosed with

diabetes.

n Until there is better evidence, clinicians should

discuss screening for GDM with their patients and

make case-by-case decisions. Discussions should

include information about the uncertainty of

benefits and harms as well as the frequency of

positive screening test results.

n Women who are obese, older than 25 years of age,

have a family history of diabetes, have a history of

previous GDM, or are of certain ethnic groups

(Hispanic, American Indian, Asian, or AfricanAmerican) are at increased risk of developing

GDM.

n In the United States, the most common screening

test is an initial 50-gram 1-hour glucose challenge

test (GCT). If the result of the GCT is abnormal,

variably defined as either greater than 130 mg/dL or
184

140 mg/dL, the patient undergoes a 100-gram 3-

hour oral glucose tolerance test (OGTT). Two or

more abnormal values on the OGTT are considered

a diagnosis of GDM.

n Most screening is conducted between 24 and 28

weeks gestation. There is little evidence about the

value of earlier screening.

n Treatment usually includes recommendations for

physical activity and dietary modification. In

addition, treatment sometimes includes medication

(either insulin or oral hypoglycemic agents),

support from diabetes educators and nutritionists,

and increased surveillance in prenatal care. The

extent to which these interventions improve health

outcomes is uncertain.

n Nearly all pregnant women should be encouraged

to achieve moderate weight gain based on their prepregnancy body mass index (BMI) and to

participate in physical activity.

This USPSTF recommendation was first published in:

Ann Intern Med. 2008; 148:759-765.

Screening for Gestational Diabetes Mellitus
Clinical Considerations

n Administration of a full (300μg) dose of Rh (D)

immunoglobulin is recommended for all

unsensitized Rh (D)-negative women after repeated

antibody testing at 24-28 weeks’ gestation.

n If an Rh (D)-positive or weakly Rh (D)-positive

(e.g., Du

-positive) infant is delivered, a dose of Rh

(D) immunoglobulin should be repeated

postpartum, preferably within 72 hours after

delivery. Administering Rh (D) immunoglobulin at

other intervals after delivery has not been studied.

n Unless the biological father is known to be Rh (D)-

negative, a full dose of Rh (D) immunoglobulin is

recommended for all unsensitized Rh (D)-negative

women after amniocentesis and after induced or

185

Screening for Rh (D) Incompatibility

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) strongly recommends Rh (D) blood

typing and antibody testing for all pregnant

women during their first visit for pregnancy-related

care. Grade: A Recommendation.

The USPSTF recommends repeated Rh (D)

antibody testing for all unsensitized Rh (D)-

negative women at 24-28 weeks’ gestation, unless

the biological father is known to be Rh (D)-

negative. Grade: B Recommendation.
Screening for Rh (D) Incompatibility

186

spontaneous abortion; however, if the pregnancy is

less than 13 weeks, a 50 μg dose is sufficient.

n The benefit of routine administration of Rh (D)

immunoglobulin after other obstetric procedures or

complications such as chorionic villus sampling,

ectopic pregnancy termination, cordocentesis, fetal

surgery or manipulation (including external

version), antepartum placental hemorrhage,

abdominal trauma, antepartum fetal death, or

stillbirth is uncertain due to inadequate evidence.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. February 2004. http://www.USPreventiveServicesTask

Force.org.
Clinical Considerations

n Primary open angle glaucoma (POAG) is a chronic

condition characterized by a loss of retinal ganglion

cell axons. It is manifested initially by peripheral

visual field loss; in an uncertain number of cases, it

progresses to impairment in important visionrelated function and even to irreversible blindness.

n The diagnosis of POAG is not made on the basis of

a single test but on the finding of characteristic

degenerative changes in the optic disc and defects in

visual fields. Although increased intraocular pressure

(IOP) has previously been considered an important

part in the definition of this condition, it is now

known that many people with POAG do not have

increased IOP; hence, there is little value of using

tonometry to screen for POAG.

Vision Disorders

Screening for Glaucoma

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) found insufficient evidence to

recommend for or against screening adults for

glaucoma. Grade: I Statement.

187
n Increased IOP, family history, older age, and being

of African American descent place an individual at

increased risk for glaucoma. Older African

Americans have a higher prevalence of glaucoma

and perhaps a more rapid disease progression, and if

it is shown that screening for glaucoma reduces the

development of visual impairment, African

Americans would likely have greater absolute

benefit than whites. People with a limited life

expectancy would likely have little to gain from

glaucoma screening.

n The natural history of glaucoma is heterogeneous

and not well defined. There is a subgroup of people

with POAG in whom there is either no disease

progression, or the progression is so slow that the

condition would never have an important effect on

their vision. The size of this subgroup is uncertain

and may depend on the ethnicity and age of the

population. Others experience more rapidly

progressing disease, leading to reduced visionrelated function within 10 years. Whether an

individual’s glaucoma will progress cannot be

predicted with precision, but those with higher

levels of IOP and worse visual fields at baseline, and

those who are older, tend to be at greater risk for

the more rapid progression of glaucoma. Whether

the rate of progression of visual field defects remains

uniform throughout the course of glaucoma is

unknown.

188

Screening for Glaucoma
n Measurement of visual fields can be difficult. The

reliability of a single visual field measurement may

be low; several consistent visual field measurements

are needed to establish the presence of defects.

Dilated opthalmoscopy or slit lamp exam are used

by specialists to examine changes in the optic disc;

however, even experts vary in their ability to detect

glaucomatous optic disc progression. Additionally,

there is no agreed-upon single standard to define

and measure progression of visual field defects.

n The primary treatments for POAG reduce IOP;

these include medications, laser therapy, or surgery.

These treatments effectively reduce the development

and progression of small, visual field defects. The

magnitude of their effectiveness, however, in

reducing impairment in vision-related function is

uncertain. Harms caused by these interventions

include formation of cataracts, harms resulting from

cataract surgery, and harms of topical medication.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality. Rockville,

MD. March 2005. http://www.USPreventiveServicesTask

Force.org.

189

Screening for Glaucoma
Screening for Impaired Visual Acuity in

Older Adults

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to assess the balance of benefits and

harms of screening for visual acuity for the

improvement of outcomes in older adults. Grade: I

Statement.

Clinical Considerations

n This recommendation statement applies to adults

65 years or older.

n Older age is an important risk factor for most types

of visual impairment. Additional risk factors for

cataracts are smoking, alcohol use, exposure to

ultraviolet light, diabetes, corticosteroid use, and

black race. Risk factors for AMD include smoking,

family history, and white race.

n A visual acuity test (for example, the Snellen eye

chart) is the usual method for screening for visual

acuity impairment in the primary care setting.

Screening questions are not as accurate as visual

acuity testing for identifying visual acuity

impairment. Evidence is limited on the use of other

vision tests, including pinhole testing, the Amsler

grid (a chart used to test central vision in order to

detect AMD), or funduscopy (visual inspection of

the interior of the eye), in screening in primary care

to detect visual impairment due to AMD or

cataracts.

190
n Most older adults will need some type of corrective

lenses. The treatment for cataracts is surgical

removal of the cataract. Treatments for exudative (or

wet) AMD include laser photocoagulation,

verteporfin, and intravitreal injections of vascular

endothelial growth factor inhibitors. Antioxidant

vitamins and minerals are treatments for dry AMD,

but evidence about their effectiveness is limited.

n This recommendation does not cover screening for

glaucoma. The USPSTF review and

recommendation statement on screening for

glaucoma are available on the USPSTF Web site

(http://www.USPreventiveServicesTaskForce.org).

Poor visual acuity is a risk factor for falls in older

aduts. A USPSTF recommendation on preventing

falls in older adults is in progress and will be

available at the above Web site.

This USPSTF recommendation was first published in:

Ann Intern Med. 2009; 151:37-43.

191

Impaired Visual Acuity in Older Adults
All recommendation statements in this Guide are

abridged. To see the full recommendation statements

and recommendations published after March 2010,

go to http://www.USPreventiveServicesTaskForce.org.

Section 3.

Recommendations

for Children and

Adolescents
Clinical Considerations

n This USPSTF recommendation addresses screening

for elevated blood levels in children aged 1 to 5

years who are both at average and increased risk,

and in asymptomatic pregnant women.

n The highest mean blood lead levels in the U.S.

occur in children aged 1-5 years (geometric mean

1.9 μg/dL). Children under 5 years of age are at

greater risk for elevated blood lead levels and lead

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) concludes that evidence is insufficient

to recommend for or against routine screening for

elevated blood lead levels in asymptomatic children

aged 1 to 5 who are at increased risk. Grade: I

Statement.

The USPSTF recommends against routine

screening for elevated blood lead levels in

asymptomatic children aged 1 to 5 years who are

at average risk. Grade: D Recommendation.

The USPSTF recommends against routine

screening for elevated blood lead levels in

asymptomatic pregnant women. Grade: D

Recommendation.

195

Screening for Elevated Blood Lead

Levels in Children and Pregnant Women
toxicity because of increased hand-to-mouth

activity, increased lead absorption from the

gastrointestinal tract, and the greater vulnerability

of the developing central nervous system. Risk

factors for increased blood lead levels in children

and adults include: minority race/ethnicity; urban

residence; low income; low educational attainment;

older (pre-1950) housing; recent or ongoing home

renovation or remodeling; pica exposure; use of

ethnic remedies, certain cosmetics, and exposure to

lead-glazed pottery; occupational and paraoccupational exposures; and recent immigration.

Risk factors for pregnant women include alcohol

use, smoking, pica, and recent immigration status.

n Blood lead levels in childhood, after peaking at

about 2 years of age, decrease during short- and

long-term followup without intervention. Most lead

is stored in bone. High bone lead levels can be

present with normal blood lead levels, so that blood

lead levels often do not reflect the total amount of

lead in the body. This could explain the lack of

effect of blood lead level-lowering measures on

reducing neurotoxic effects.

n Screening tests for elevated blood lead levels include

free erythrocyte (or zinc) protoporphyrin levels and

capillary or venous blood lead levels. Erythrocyte

(or zinc) protoporphyrin is insensitive to modest

elevations in blood lead levels and lacks specificity.

Blood lead concentration is more sensitive than

196

Screening for Blood Lead Levels
erythrocyte protoporphyrin for detecting modest

lead exposure, but its accuracy, precision, and

reliability can be affected by environmental lead

contamination. Therefore, venous blood lead level

testing is preferred to capillary sampling. Screening

questionnaires may be of value in identifying

children at risk for elevated blood lead levels but

should be tailored for and validated in specific

communities for clinical use.

n Treatment options in use for elevated blood lead

levels include residential lead hazard-control efforts

(i.e., counseling and education, dust or paint

removal, and soil abatement), chelation, and

nutritional interventions. In most settings,

education and counseling is offered for children

with blood lead levels from 10 to 20 μg/dL. Some

experts have also recommended nutritional

counseling for children with blood lead levels in this

range. Residential lead hazard control is usually

offered to children with blood lead levels ≥20

μg/dL, while chelation therapy is offered to children

with blood lead levels ≥45 μg/dL.

n Community-based interventions for the primary

prevention of lead exposure are likely to be more

effective, and may be more cost-effective, than

office-based screening, treatment, and counseling.

Relocating children who do not yet have elevated

blood lead levels but who live in settings with high

lead exposure may be especially helpful.

197

Screening for Blood Lead Levels
Community, regional, and national environmental

lead hazard reduction efforts, such as reducing lead

in industrial emissions, gasoline, and cans, have

proven highly effective in reducing population

blood lead levels.

This USPSTF recommendation was first published in:

Pediatrics. 2006; 118:e2514-e2518.

198

Screening for Blood Lead Levels
199

Screening for Congenital

Hypothyroidism

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for congenital

hypothyroidism (CH) in newborns. Grade: A

Recommendation.

Clinical Considerations

n This recommendation applies to all infants born in

the U.S. Premature, very low birth weight and ill

infants may benefit from additional screening

because these conditions are associated with

decreased sensitivity and specificity of screening

tests.

n Screening for CH is mandated in all 50 states and

the District of Columbia, though methods of

screening vary. There are two main methods used in

the U.S.: Primary TSH with backup T4; and

primary T4 with backup TSH. A few states use

both tests in initial screening. Clinicians should

become familiar with the tests used in their area and

the limitations of the employed screening strategy.

For example, a primary TSH method may be falsely

negative in low and very low birth weight infants

with CH because of delayed elevation in TSH.

Additionally, few states currently screen for

centrally-mediated congenital hypothyroidism.

Families should be provided with appropriate

information about newborn screening tests,
including the benefits and harms of screening. They

should be aware of the potential of a false positive

test, and the process required for definitive testing.

Nationally, only 1 in 25 positive screening tests are

confirmed to be CH. Normal newborn screening

results for CH should not preclude appropriate

evaluation of infants presenting with clinical signs

and symptoms suggestive of hypothyroidism.

n Infants should be tested between 2 and 4 days of

age. Infants discharged from hospitals before 48

hours of life should be tested immediately before

discharge. Specimens obtained in the first 24-48

hours of age may be falsely elevated for TSH

regardless of the screening method used.

n Primary care clinicians should ensure that infants

with abnormal screens receive confirmatory testing

and begin appropriate treatment with thyroid

hormone replacement within 2 weeks after birth.

Children with positive confirmatory testing in

whom no permanent cause of CH is found (such as

lack of thyroid tissue on thyroid ultrasound or

thyroid scan), should, at some time point after the

age of 3 years, undergo a 30-day trial of reduced or

discontinued thyroid hormone replacement therapy

to determine if the hypothyroidism is permanent or

transient.

This USPSTF recommendation was first published in:

Ann Fam Med. 2008; 6(2):166.

200

Screening for Congenital Hypothyroidism
Clinical Considerations

n This USPSTF screening recommendation applies

only to infants who do not have obvious hip

dislocations or other abnormalities evident without

screening. Developmental dysplasia of the hip

(DDH) represents a spectrum of anatomic

abnormalities in which the femoral head and the

acetabulum are aligned improperly or grow

abnormally. DDH can lead to premature

degenerative joint disease, impaired walking, and

pain. Risk factors for DDH include female gender,

family history of DDH, breech positioning, and in

utero postural deformities. However, the majority of

cases of DDH have no identifiable risk factors.

n Screening tests for DDH have limited accuracy. The

most common methods of screening are serial

physical examinations of the hip and lower

extremities, using the Barlow and Ortolani

procedures, and ultrasonography. The Barlow

examination is performed by adducting a flexed hip

with gentle posterior force to identify a dislocatable

Screening for Developmental Dysplasia

of the Hip

201

Summary of Recommendation

The USPSTF concludes that evidence is

insufficient to recommend routine screening for

developmental dysplasia of the hip in infants as a

means to prevent adverse outcomes. Grade: I

Statement.
Screening for Hip Dysplasia

202

hip. The Ortolani examination is performed by

abducting a flexed hip with gentle anterior force to

relocate a dislocated hip. Data assessing the relative

value of limited hip abduction as a screening tool

are sparse and suggest the test is of little value in

early infancy and is of somewhat greater value as

infants age.

n Treatments for DDH include both nonsurgical and

surgical options. Nonsurgical treatment with

abduction devices is used in early treatment and

includes the commonly prescribed Pavlik method.

Surgical intervention is used when DDH is severe

or diagnosed late or after an unsuccessful trial of

nonsurgical treatments. Evidence of the effectiveness

of interventions is inconclusive because of a high

rate of spontaneous resolution, absence of

comparative studies of intervention versus

nonintervention groups, and variations in surgical

indications and protocols. Avascular necrosis of the

hip is the most common and most severe potential

harm of both surgical and nonsurgical interventions

and can result in growth arrest of the hip and

eventual joint destruction with significant disability.

This USPSTF recommendation was first published in:

Pediatrics. 2006; 117:898-902.
Screening of Infants for

Hyperbilirubinemia to Prevent

Chronic Bilirubin Encephalopathy

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend screening infants for

hyperbilirubinemia to prevent chronic bilirubin

encephalopathy. Grade: I Statement.

Clinical Considerations

n Potential preventable burden: Severe neonatal

hyperbilirubinemia is associated with kernicterus,

the yellow staining of specific areas of brain tissue in

the neonate caused by accumulation of

unconjugated bilirubin. Chronic bilirubin

encephalopathy describes the clinical neurologic

sequelae associated with severe hyperbilirubinemia,

including choreoathetoid cerebral palsy,

sensorineural hearing loss, gaze paresis, and

intellectual deficits. However, hyperbilirubinemia

alone is not sufficient to account for these

neurologic findings. Infants with extremely high

levels of serum bilirubin but no apparent sequelae

have been reported, and infants without

documented high serum levels of bilirubin have

been found to have kernicterus. While U.S. figures

are not available, incidence of bilirubin

encephalopathy in the U.K. is estimated at 0.9 in

100,000 live births.

203
n Potential harms: Potential harms caused by

interference with breastfeeding, disruption of

maternal-infant bonding, pain caused by heel stick

or venipuncture, weight loss, gastrointestinal

problems, possible growth of melanocytic nevi, and

labeling of infants that have elevated bilirubin levels

are unmeasured but may be important.

n Costs: The monetary cost to provide universal

screening would be very large, particularly if serum

or transcutaneous bilirubin (TcB) measurement is

adopted as a universal screening tool.

n Current practice: Universal screening with a variety

of methods is widespread in the United States.

n This recommendation statement addresses screening

for hyperbilirubinemia to reduce the incidence of

chronic bilirubin encephalopathy in healthy term or

near-term infants (≥ 35 weeks’ gestational age).

n Risk factors for hyperbilirubinemia include

exclusive breastfeeding, family history of neonatal

jaundice, bruising, cephalohematoma, ethnicity

(Asian, black), maternal age (> 25 years), male

gender, glucose-6-phosphate dehydrogenase

deficiency, and gestational age of < 38 weeks. The

contribution of these risk factors to chronic

bilirubin encephalopathy in otherwise healthy

children is not well understood.

n Screening for hyperbilirubinemia may consist of

risk-factor assessment, measurement of bilirubin

level (either in serum or by transcutaneous

estimation), or a combination of methods.

204

Screening Infants for Hyperbilirubinemia
n Phototherapy is commonly used to treat

hyperbilirubinemia. A previous systematic review

reported that one needs to treat 6 to 10 otherwise

healthy jaundiced neonates with total serum

bilirubin (TSB) levels of ≥15 mg/dL with

phototherapy to prevent the TSB level in 1

additional infant from rising above 20 mg/dL.

Exchange transfusion is used to treat extreme

hyperbilirubinemia. Although death as a

complication of exchange transfusion is rare,

significant morbidity (apnea, bradycardia, cyanosis,

vasospasm, thrombosis, or necrotizing enterocolitis

occurs in as any as 5% of exchange transfusions,

and the risks associated with the use of blood

products must always be considered. Hypoxicischemic encephalopathy and AIDS have occurred

in otherwise healthy infants receiving exchange

transfusions.

This USPSTF recommendation was first published in:

Pediatrics. 2009; 124:1172-1177.

205

Screening Infants for Hyperbilirubinemia
Screening for Idiopathic Scoliosis in

Adolescents

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends against the routine

screening of asymptomatic adolescents for

idiopathic scoliosis. Grade: D Recommendation.

Clinical Considerations

n Screening adolescents for idiopathic scoliosis is

usually done by visual inspection of the spine to

look for asymmetry of the shoulders, scapulae, and

hips. A scoliometer can be used to measure the

curve. If idiopathic scoliosis is suspected,

radiography can be used to confirm the diagnosis

and to quantify the degree of curvature.

n The health outcomes of adolescents with idiopathic

scoliosis differ from those of adolescents with

secondary scoliosis (i.e., congenital, neuromuscular,

or early onset idiopathic scoliosis). Idiopathic

scoliosis with onset in adolescence may have a

milder clinical course.

n Conservative interventions to treat curves detected

through screening include spinal orthoses (braces)

and exercise therapy, but they may not significantly

improve back pain or the quality of life for

adolescents diagnosed with idiopathic scoliosis.

206
Screening for Idiopathic Scoliosis in Adolescents

207

n The potential harms of screening and treating

adolescents for idiopathic scoliosis include

unnecessary follow-up visits and evaluations due to

false positive test results and psychological adverse

effects, especially related to brace wear. Although

routine screening of adolescents for idiopathic

scoliosis is not recommended, clinicians should be

prepared to evaluate idiopathic scoliosis when it is

discovered incidentally or when the adolescent or

parent expresses concern about scoliosis.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville,

MD. June 2004. http://www.USPreventiveServicesTask

Force.org.
Screening for Lipid Disorders in Children

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend for or against routine

screening for lipid disorders in infants, children,

adolescents, or young adults (up to age 20). Grade:

I Statement.

Clinical Considerations

n Dyslipidemias are abnormalities of lipoprotein

metabolism and include elevations in TC, LDL-C,

or triglycerides or deficiencies of HDL-C. These

disorders can be acquired or familial; monogenic

dyslipidemias are related to genetic conditions such

as familial hypercholesterolemia in some

individuals. Multifactorial dyslipidemias are due to

risk factors including environmental factors (obesity,

diet) or currently unidentified genetic factors. This

recommendation applies to all asymptomatic

individuals from birth to age 20.

n Because normal lipid levels have been strongly

associated with the risk of coronary heart disease

(CHD) events in adulthood, and early

identification and lipid-lowering intervention in

certain populations of adults can prevent CHD

events, much attention has been directed at

screening individuals for dyslipidemia at young ages

208
(e.g., childhood). Among children and adolescents,

3 groups may be identified through screening:

1. Children with undiagnosed monogenic

dyslipidemias such as familial

hypercholesterolemia.

2. Those with undiagnosed secondary causes

of dyslipidemia.

3. Those with multi-factorial dyslipidemia

(polygenetic or related to risk-factors).

However, the clinical health benefits shown in

adults identified and treated for dyslipidemia have

not been studied in children, making the role of

screening children uncertain.

n Children and adolescents with diabetes may be at

especially high risk for dyslipidemia and

cardiovascular events. Screening children and

adolescents with diabetes for dyslipidemia has been

recommended by other groups as a part of

appropriate care for these children.

n The use of family history as a screening tool for

dyslipidemia has variable accuracy largely because

definitions of a positive family history and lipid

threshold values vary substantially. Screening using

family history as defined by the National

Cholesterol Education Program (NCEP) and the

American Academy of Pediatrics (AAP) has been

shown to have high rates of false negative results.

Screening for Lipid Disorders in Children

209
n If clinicians choose to screen for dyslipidemia, the

preferred screening tests are TC and HDL-C on

nonfasting or fasting samples; calculating LDL-C

requires fasting samples.

This USPSTF recommendation was first published in:

Pediatrics. 2007; 120:e215-e219.

210

Screening for Lipid Disorders in Children
Screening and Treatment for Major

Depressive Disorder in Children and

Adolescents

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening of adolescents

(12-18 years of age) for major depressive disorder

(MDD) when systems are in place to ensure

accurate diagnosis, psychotherapy (cognitivebehavioral or interpersonal), and follow-up. Grade:

B Recommendation.

The USPSTF concludes that the current

evidence is insufficient to assess the balance of

benefits and harms of screening of children (7-11

years of age). Grade: I Statement.

Clinical Considerations

n This USPSTF recommendation addresses screening

for MDD in adolescents (12-18 years of age) and

children (7-11 years of age) in the general

population. There is a spectrum of depressive

disorders. This report focuses only on screening for

MDD and does not address screening for various

less-severe depressive disorders.

n A variety of factors contribute to the development

of MDD. Most people who develop MDD have

multiple risk factors. However, risk factors for

MDD can be difficult to assess. As a result,

researchers have focused on identifying youth

211
subgroups at increased risk of developing MDD.

Important risk factors that can be assessed relatively

accurately and reliably include parental depression,

having comorbid mental health or chronic medical

conditions, and having experienced a major

negative life event.

n Instruments developed for primary care (Patient

Health Questionnaire for Adolescents [PHQ-A] and

the Beck Depression Inventory-Primary Care

Version [BDI-PC]) have been used successfully in

adolescents. There are limited data describing the

accuracy of using MDD screening instruments in

younger children (7-11 years of age).

n Among pharmacotherapies available for the

treatment of MDD in children and adolescents,

SSRIs have been found to be efficacious. Treating

depressed youth with SSRIs is associated with an

increased risk of suicidality and, therefore, should

only be considered if judicious clinical monitoring

is possible. Psychotherapy trials indicate that a

variety of psychotherapy types are efficacious among

adolescents (including cognitive-behavioral and

interpersonal therapies). Harms of psychotherapy

are felt to be small.

This USPSTF recommendation was first published in:

Pediatrics. 2009; 123:1223–1228

212

Screening for Depressive Disorder in Children
213

Universal Screening for Hearing Loss

in Newborns

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for hearing loss

in all newborn infants. Grade: B Recommendation.

Clinical Considerations

n The patient population considered here includes all

newborn infants.

n Risk factors associated with a higher incidence of

permanent bilateral congenital hearing loss include

NICU admission for ≥2 days, several congenital

syndromes, family history of hereditary childhood

sensorineural hearing loss, craniofacial abnormalities,

and certain congenital infections. However, ~50%

of infants with permanent bilateral congenital

hearing loss do not have any known risk factors.

n Screening programs should be conducted by using a

1- or 2-step validated protocol. A frequently used

protocol requires a 2-step screening process, which

includes otoacoustic emissions (OAEs) followed by

auditory brainstem response (ABR) in those who

failed the first test. Equipment should be well

maintained, staff should be thoroughly trained, and

quality-control programs should be in place to

reduce avoidable false-positive test results. Programs

should develop protocols to ensure that infants with

positive screening-test results receive appropriate
audiologic evaluation and follow-up after discharge.

Newborns delivered at home, birthing centers, or

hospitals without hearing screening facilities should

have some mechanism for referral for newborn

hearing screening, including tracking of follow-up.

n Early intervention services for hearing-impaired

infants should be designed to meet the

individualized needs of the infant and family,

including acquisition of communication

competence, social skills, emotional well-being, and

positive self-esteem. Early intervention includes

evaluation for amplification or sensory devices,

surgical and medical evaluation, and

communication assessment and therapy. In recent

years, cochlear implants have become more available

for appropriate candidates; this surgery is usually

considered in those with severe-to-profound hearing

loss only after inadequate response to hearing aids.

n All infants should have hearing screening before 1

month of age. Those infants who do not pass the

newborn screening should undergo audiologic and

medical evaluation before 3 months of age for

confirmatory testing. Because of the elevated risk of

hearing loss in infants with risk indicators, an expert

panel made a recommendation in 2000 that these

children should undergo periodic monitoring for 3

years.

This USPSTF recommendation was first published in:

Pediatrics. 2008; 122:143–148.

214

Screening for Hearing Loss in Newborns
Screening for Obesity in Children

and Adolescents

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends that clinicians screen

children aged 6 years and older for obesity and

offer them or refer them to comprehensive,

intensive behavioral interventions to promote

improvement in weight status. Grade: B

Recommendation.

Clinical Considerations

n This recommendation statement applies to children

and adolescents aged 6 to 18 years. The USPSTF is

using the following terms to define categories of

increased BMI: overweight is defined as an age- and

gender-specific BMI between the 85th and 95th

percentiles, and obesity is defined as an age- and

gender-specific BMI at ≥95th percentile. The

USPSTF did not find sufficient evidence for

screening children younger than 6 years.

n In 2005, the USPSTF found adequate evidence that

BMI was an acceptable measure for identifying

children and adolescents with excess weight. BMI is

calculated from the measured weight and height of

an individual.

n The USPSTF found that effective comprehensive

weight-management programs incorporated

counseling and other interventions that targeted

diet and physical activity. Interventions also

215
included behavioral management techniques to

assist in behavior change. Interventions that focused

on younger children incorporated parental

involvement as a component.

Moderate- to high-intensity programs involved >25

hours of contact with the child and/or the family

over a 6-month period and showed results including

improved weight status, defined as an absolute

and/or relative decrease in the BMI 12 months after

the beginning of the intervention. Most participants

were obese, and it is not known whether these

results can be applied to children who are

overweight but not obese. In addition, evidence was

limited on the long-term sustainability of BMI

changes achieved through behavioral interventions

and on the trajectory of weight gain in children and

adolescents. Interventions generally took place in

referral settings, and the results can only be

generalized to children who follow through on

treatment. Low-intensity interventions, defined as

≤25 contact hours over a 6-month period, did not

result in significant improvement in weight status.

Interventions that combined pharmacologic agents

(sibutramine or orlistat) with behavioral

interventions resulted in modest short-term

improvement in weight status in children aged 12

years and older. There were no long-term data on

the maintenance of improvement after

discontinuation of medications. The magnitude of

the harms of these drugs in children could not be

estimated with certainty. Adverse effects included

216

Screening for Obesity in Children and Adolescents
elevated heart rate, elevated blood pressure, and

adverse gastrointestinal effects. Sibutramine, a

centrally acting appetite suppressant, has been

approved by the US Food and Drug Administration

(FDA) for use in adolescents aged 16 years and

older. Orlistat, a lipase inhibitor, has been approved

by the FDA for use in adolescents aged 12 years

and older. Neither sibutramine nor orlistat has been

approved for use in pediatric populations younger

than 12 years.

n No evidence was found regarding appropriate

intervals for screening. Height and weight, from

which BMI is calculated, are routinely measured

during health maintenance visits.

This USPSTF recommendation was first published in:

Pediatrics. 2010; 125:361-367.

217

Screening for Obesity in Children and Adolescents
Screening for Phenylketonuria

Summary of Recommendations

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for

phenylketonuria (PKU) in newborns. Grade: A

Recommendation.

Clinical Considerations

n This recommendation applies to newborns.

n Screening for PKU is mandated in all 50 states,

though methods of screening vary. There are three

principal methods used for PKU screening in the

United States: the Guthrie Bacterial Inhibition

Assay (BIA), automated fluorometric assay, and

tandem mass spectrometry. Screening tests are most

accurate if performed after 24 hours of life but

before the infant is 7 days old.

n It is essential that phenylalanine restrictions be

instituted shortly after birth to prevent the

neurodevelopmental effects of PKU.

n Infants who are tested within the first 24 hours after

birth should receive a repeat screening test by 2

weeks of age. Premature infants and those with

illnesses should be tested at or near 7 days of age,

but in all cases before newborn nursery discharge.

This USPSTF recommendation was first published in:

Ann Fam Med. 2008; 6(2):166.

218
Screening for Sickle Cell Disease

in Newborns

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends screening for sickle cell

disease in newborns. Grade: A Recommendation.

Clinical Considerations

n Screening for sickle cell disease in newborns is

mandated in all 50 States and the District of

Columbia. Most States use either thin-layer

isoelectric focusing (IEF) or high performance

liquid chromatography (HPLC) as the initial

screening test. Both methods have extremely high

sensitivity and specificity for sickle cell anemia.

Specimens must be drawn prior to any blood

transfusion due to the potential for a false negative

result as a result of the transfusion. Extremely

premature infants may have false positive results

when adult hemoglobin is undetectable.

n All newborns should undergo testing regardless of

birth setting. In general, birth attendants should

make arrangements for samples to be obtained, and

the first physician to see the child at an office visit

should verify screening results. Confirmatory testing

should occur no later than 2 months of age.

219
n Children with sickle cell anemia should begin

prophylactic penicillin by 2 months of age and

receive pneumococcal immunizations at

recommended intervals.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville, MD.

September 2007. http://www.USPreventiveServicesTask

Force.org.

220

Screening for Sickle Cell Disease in Newborns
Screening for Speech and Language

Delay in Preschool Children

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend for or against routine

use of brief, formal screening instruments in

primary care to detect speech and language delay in

children up to 5 years of age. Grade: I Statement.

Clinical Considerations

n It is the responsibility of primary care clinicians to

seek and address parents’ concerns and children’s

obvious speech and language delays despite the lack

of evidence to support screening with brief formal

instruments. Speech and language development is

considered a useful early indicator of a child’s

overall development and cognitive ability, and

clinical and parental concerns are important modes

of identifying children with speech and language

delay. Early identification of children with

developmental delay (lateness in achieving

milestones) or developmental disabilities (chronic

conditions that result from mental or physical

impairments), such as marked hearing deficits, may

lead to intervention and family assistance at a young

age when chances for improvement may be best.

221
n Specific groups of children who already have been

identified as at higher than average risk for speech

and language delay, including children with other

medical problems such as hearing deficits or craniofacial abnormalities, are not considered in this

recommendation. The results of studies of other risk

factors are inconsistent, so the USPSTF was unable

to develop a list of specific risk factors to guide

primary care providers in selective screening. The

most consistently reported risk factors, however,

include a family history of speech and language

delay, male gender, and perinatal factors, such as

prematurity and low birth-weight. Other risk

factors reported less consistently include levels of

parental education, specific childhood illnesses,

birth order, and larger family size.

This USPSTF recommendation was first published in:

Pediatrics. 2006; 117(2):497-501.

222

Screening for Speech and Language Delay
Counseling to Prevent Tobacco Use and

Tobacco-Caused Disease

NOTE: An update to this recommendation is in

progress. Please visit our Web site at

http://www.USPreventiveServicesTaskForce.org or the

USPSTF’s Electronic Preventive Services Selector

(ePSS) at http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendations

The USPSTF concludes that the evidence is

insufficient to recommend for or against routine

screening for tobacco use or interventions to

prevent and treat tobacco use and dependence

among children or adolescents. Grade: I Statement.

Clinical Considerations

n There is little evidence addressing the effectiveness

of screening and counseling children or adolescents

to prevent the initiation of tobacco use and to

promote its cessation in a primary care setting, but

clinicians may use their discretion in conducting

tobacco-related discussions with this population,

since the majority of adult smokers begin tobacco

use as children or adolescents.

This USPSTF recommendation was first published by:

Agency for Healthcare Research and Quality, Rockville, MD.

November 2003. http://www.USPreventiveServicesTask

Force.org.

223
Screening for Visual Impairment in

Children Younger Than Age 5 Years

NOTE: An update to this recommendation is in

progress. Please visit the USPSTF Web site at

http://www.USPreventiveServicesTaskForce.org or the

Electronic Preventive Services Selector (ePSS) at

http://epss.ahrq.gov for the most current

recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force

(USPSTF) recommends screening to detect

amblyopia, strabismus, and defects in visual acuity

in children younger than age 5 years. Grade: B

Recommendation.

Clinical Considerations

n The most common causes of visual impairment in

children are: (1) amblyopia and its risk factors and

(2) refractive error not associated with amblyopia.

Amblyopia refers to reduced visual acuity without a

detectable organic lesion of the eye and is usually

associated with amblyogenic risk factors that

interfere with normal binocular vision, such as

strabismus (ocular misalignment), anisometropia (a

large difference in refractive power between the 2

eyes), cataract (lens opacity), and ptosis (eyelid

drooping). Refractive error not associated with

amblyopia principally includes myopia

(nearsightedness) and hyperopia (farsightedness);

224
both remain correctable regardless of the age at

detection.

n Various tests are used widely in the United States to

identify visual defects in children, and the choice of

tests is influenced by the child’s age. During the

first year of life, strabismus can be assessed by the

cover test and the Hirschberg light reflex test.

Screening children younger than age 3 years for

visual acuity is more challenging than screening

older children and typically requires testing by

specially trained personnel. Newer automated

techniques can be used to test these children.

Photoscreening can detect amblyogenic risk factors

such as strabismus, significant refractive error, and

media opacities; however, photoscreening cannot

detect amblyopia.

n Traditional vision testing requires a cooperative,

verbal child and cannot be performed reliably until

ages 3 to 4 years. In children older than age 3 years,

stereopsis (the ability of both eyes to function

together) can be assessed with the Random Dot E

test or Titmus Fly Stereotest; visual acuity can be

assessed by tests such as the HOTV chart, Lea

symbols, or the tumbling E. Some of these tests

have better test characteristics than others.

n Based on their review of current evidence, the

USPSTF was unable to determine the optimal

screening tests, periodicity of screening, or technical

proficiency required of the screening clinician.

Based on expert opinion, the American Academy of

225

Visual Impairment in Children Younger Than Age 5 Years
Pediatrics (AAP) recommends the following vision

screening be performed at all well-child visits for

children starting in the newborn period to 3 years:

ocular history, vision assessment, external inspection

of the eyes and lids, ocular motility assessment,

pupil examination, and red reflex examination. For

children aged 3 to 5 years, the AAP recommends

the aforementioned screening in addition to ageappropriate visual acuity measurement (using

HOTV or tumbling E tests) and ophthalmoscopy.

n The USPSTF found that early detection and

treatment of amblyopia and amblyogenic risk

factors can improve visual acuity. These treatments

include surgery for strabismus and cataracts; use of

glasses, contact lenses, or refractive surgery

treatments to correct refractive error; and visual

training, patching, or atropine therapy of the

nonamblyopic eye to treat amblyopia.

n These recommendations do not address screening

for other anatomic or pathologic entities, such as

macro cornea, cataracts, retinal abnormalities, or

neonatal neuroblastoma, nor do they address newer

screening technologies currently under

investigation.

This USPSTF recommendation was first published in:

Ann Fam Med. 2004; 2:263-266.

226

Visual Impairment in Children Younger Than Age 5 Years
Appendixes

and Index
2

28

AppendixA

Appendix A

Grade Definition Suggestions for PracticeA The USPSTF recommends the service. There is Offer or provide this service.

high certainty that the net benefit is substantial.

How the U.S. Preventive Services Task Force Grades Its Recommendations

The U.S. Preventive Services Task Force (USPSTF) assigns one of five letter grades to each of its

recommendations (A, B, C, D, or I). The USPSTF changed its grade definitions based on a change in

methods in May 2007.

Grade Definitions After May 2007

What the Grades Mean and Suggestions for Practice

The USPSTF updated its definitions of the grades it assigns to recommendations and now includes

“

suggestions for practice” associated with each grade. The USPSTF has also defined levels of certainty

regarding net benefit. These definitions apply to USPSTF recommendations voted on after May 2007.

continued
Appendix A

229

Grade Definition Suggestions for PracticeB

The USPSTF recom

mends the service. There is Offer or provide this service.

high certainty that the net benefit is moderate or

there is moderate certainty that the net benefit is

moderate to substantial.

C

The USPSTF recom

mends against routinely Offer or provide this service only if

providing the service. There may be considerations other considerations support the

that support providing the service in an individual offering or providing the service

patient. There is at least moderate certainty that in an individual patient.

the net benefit is small.

D

The USPSTF recom

mends against the service. Discourage the use of this service.

There is moderate or high certainty that the service

has no net benefit or that the harms outweigh the

benefits.

I Read the clinical considerations section

Statement The USPSTF concludes that the current evidence of USPSTF Recom

mendation

is insufficient to assess the balance of benefits and Statement. If the service is offered,

harms of the service. Evidence is lacking, of poor patients should understand the

quality, or conflicting, and the balance of benefits uncertainty about the balance of benefits

and harms cannot be determined. and harms.
2

30

AppendixA

Levels of Certainty Regarding Net Benefit

Level of Certainty* DescriptionHigh The available evidence usually includes consistent results from well-designed, wellconducted studies in representative primary care populations. These studies assess

the effects of the preventive service on health outcomes. This conclusion is therefore

unlikely to be strongly affected by the results of future studies.

Moderate The available evidence is sufficient to determine the effects of the preventive service

on health outcomes, but confidence in the estimate is constrained by such factors as:

• The number, size, or quality of individual studies.

• Inconsistency of findings across individual studies.

• Limited generalizability of findings to routine primary care practice.

• Lack of coherence in the chain of evidence.

As more information becomes available, the magnitude or direction of the observed

effect could change, and this change may be large enough to alter the conclusion.

continued
2

31

AppendixA

Level of Certainty* DescriptionLow The available evidence is insufficient to assess effects on health outcomes. Evidence

is insufficient because of:

• The limited number or size of studies.

• Important flaws in study design or methods.

• Inconsistency of findings across individual studies.

• Gaps in the chain of evidence.

• Findings not generalizable to routine primary care practice.

• Lack of information on important health outcomes.

More information may allow estimation of effects on health outcomes.

* The USPSTF defines certainty as “likelihood that the USPSTF assessment of the net benefit of a preventive

service is correct.” The net benefit is defined as benefit minus harm of the preventive service as implemented in

a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall

evidence available to assess the net benefit of a preventive service.
Appendix A

Grade Definitions Prior to May 2007

The definitions below (of USPSTF grades and quality of

evidence ratings) were in use prior to the update in methods

and apply to recommendations voted on by the USPSTF

prior to May 2007.

A Strongly Recommended: The USPSTF strongly

recommends that clinicians provide [the service] to

eligible patients. The USPSTF found good evidence that

[the service] improves important health outcomes and

concludes that benefits substantially outweigh harms.

B Recommended: The USPSTF recommends that

clinicians provide [the service] to eligible patients. The

USPSTF found at least fair evidence that [the service]

improves important health outcomes and concludes that

benefits outweigh harms.

C No Recommendation: The USPSTF makes no

recommendation for or against routine provision of [the

service]. The USPSTF found at least fair evidence that [the

service] can improve health outcomes but concludes that the

balance of benefits and harms is too close to justify a general

recommendation.

D Not Recommended: The USPSTF recommends against

routinely providing [the service] to asymptomatic

patients. The USPSTF found at least fair evidence that [the

service] is ineffective or that harms outweigh benefits.

I Insufficient Evidence to Make a Recommendation:

The USPSTF concludes that the evidence is insufficient

to recommend for or against routinely providing [the

service]. Evidence that [the service] is effective is lacking, of

poor quality, or conflicting and the balance of benefits and

harms cannot be determined.

232
Quality of Evidence (for recommendations prior

to May 2007)

The USPSTF grades the quality of the overall evidence

for a service on a 3-point scale (good, fair, poor):

Good: Evidence includes consistent results from welldesigned, well-conducted studies in representative

populations that directly assess effects on health

outcomes.

Fair: Evidence is sufficient to determine effects on health

outcomes, but the strength of the evidence is limited

by the number, quality, or consistency of the

individual studies, generalizability to routine

practice, or indirect nature of the evidence on health

outcomes.

Poor: Evidence is insufficient to assess the effects on health

outcomes because of limited number or power of

studies, important flaws in their design or conduct,

gaps in the chain of evidence, or lack of information

on important health outcomes.

Appendix A

233
234

Appendix B

Members of the U.S. Preventive Services

Task Force 2002-2010

Janet D. Allan, Ph.D.,

R.N., C.S., F.A.A.N.

School of Nursing,

University of Maryland,

Baltimore

Baltimore, MD

Alfred O. Berg, M.D.,

M.P.H.

University of Washington

Seattle, WA

Kirsten Bibbins-Domingo,

Ph.D., M.D.

San Francisco General

Hospital

University of California,

San Francisco, CA

Adelita Gonzales Cantu,

R.N., Ph.D.

University of Texas Health

Science Center,

San Antonio, TX

Ned Calonge, M.D., M.P.H.

Colorado Department of

Public Health and

Environment

Denver, CO

Susan Curry, Ph.D.

College of Public Health

University of Iowa

Iowa City, IA

Thomas G. DeWitt, M.D.

Department of Pediatrics,

Children’s Hospital

Medical Center

Cincinnati, OH

Allen J. Dietrich, M.D.

Dartmouth Medical School

Hanover, NH

Glenn Flores, M.D.

University of Texas

Southwestern Medical

Center and Children’s

Medical Center of Dallas

Dallas, TX

Paul S. Frame, M.D.

Tri-County Family Medicine

Cohocton, NY

Joxel Garcia, M.D., M.B.A.

Pan American Health

Organization

Washington, DC
Appendix B

235

Leon Gordis, M.D., Dr. P.H.

Johns Hopkins Bloomberg

School of Public Health

Baltimore, MD

Kimberly D. Gregory,

M.D., M.P.H.

Cedars-Sinai Medical Center

Los Angeles, CA

David Grossman, M.D.,

M.P.H.

Center for Health Studies,

Group Health

Cooperative

University of Washington

Seattle, WA

Russell Harris, M.D.,

M.P.H.

University of North

Carolina School of

Medicine

Chapel Hill, NC

Charles J. Homer, M.D.,

M.P.H.

National Initiative for

Children’s Healthcare

Quality

Boston, MA

George Isham, M.D., M.S.

HealthPartners

Minneapolis, MN

Mark S. Johnson, M.D.,

M.P.H.

New Jersey Medical School

University of Medicine and

Dentistry of New Jersey

Newark, NJ

Kenneth Kizer, M.D.,

M.P.H.

National Quality Forum

Washington, DC

Jonathan D. Klein, M.D.,

M.P.H.

University of Rochester

Rochester, NY

Tracy A. Lieu, M.D.,

M.P.H.

Harvard Pilgrim Health

Care and Harvard

Medical School

Boston, MA

Michael L. LeFevre, M.D.,

M.S.P.H.

University of Missouri

School of Medicine

Columbia, MO

Rosanne Leipzig, M.D.,

Ph.D.

Mount Sinai School of

Medicine

New York, NY
Carol Loveland-Cherry,

Ph.D., R.N., F.A.A.N.

School of Nursing

University of Michigan

Ann Arbor, MI

Lucy N. Marion, Ph.D.,

R.N.

School of Nursing, Medical

College of Georgia

Augusta, GA

Bernadette Melnyk, Ph.D.,

R.N., C.P. N.P./N.P.P.

College of Nursing &

Healthcare Innovation

Arizona State University

Phoenix, AZ

Virginia A. Moyer, M.D.,

M.P.H.

University of Texas Health

Science Center

Houston, TX

Cynthia D. Mulrow, M.D.,

M.Sc.

University of Texas Health

Science Center

Audie L. Murphy Memorial

Veterans Hospital

San Antonio, TX

Wanda Nicholson, M.D.,

M.P.H., M.B.A

Johns Hopkins School of

Medicine and Bloomberg

School of Public Health

Baltimore, MD

Judith K. Ockene, Ph.D.,

M.Ed.

University of Massachusetts

Medical School

Worcester, MA

C. Tracy Orleans, Ph.D.

The Robert Wood Johnson

Foundation

Princeton, NJ

Jeffrey F. Peipert, M.D.,

M.P.H.

Women and Infants’

Hospital

Providence, RI

Nola J. Pender, Ph.D., R.N.

School of Nursing

University of Michigan

Ann Arbor, MI

Diana B. Petitti, M.D.,

M.P.H.

Fulton School of

Engineering,

Arizona State University

Tempe, AZ

236

Appendix B
237

Appendix B

Carolina Reyes, M.D.

University of Southern

California, Los Angeles

County/USC Medical

Center

Los Angeles, CA

George F. Sawaya, M.D.

University of California,

San Francisco

San Francisco, CA

J. Sanford (Sandy)

Schwartz, M.D.

University of Pennsylvania

School of Medicine and

Wharton School

Philadelphia, PA

Harold C. Sox, Jr., M.D.

Dartmouth-Hitchcock

Medical Center

Lebanon, NH

Albert L. Siu, M.D.,

M.S.P.H.

Mount Sinai Medical Center

New York, NY

Steven M. Teutsch, M.D.,

M.P.H.

Merck and Company, Inc.

West Point, PA

Carolyn Westhoff, M.D.,

M.Sc.

Columbia University

New York, NY

Timothy Wilt, M.D.,

M.P.H.

Minneapolis VA Medical

Center

University of Minnesota

Minneapolis, MN

Steven H. Woolf, M.D.,

M.P.H.

Virginia Commonwealth

University

Fairfax, VA

Barbara P. Yawn, M.D.,

M.S.P.H., M.Sc.

Olmstead Medical Center

Rochester, MN
238

Appendix C

Acknowledgments

AHRQ Staff Supporting the USPSTF

2002-2010

David Atkins, M.D., M.P.H.

Mary Barton, M.D., M.P.P.

Joel Boches

Helen Burstin, M.D., M.P.H.

Robert Cosby, Ph.D.

Mackenzie Cross

Ellen Crown

Sandra K. Cummings

Elizabeth Edgerton, M.D., M.P.H.

Farah Englert

Saeed Fatemi

Kenneth Fink, M.D., M.G.A., M.P.H.

Janice Genevro, Ph.D., M.S.W.

Barbara Gordon

Margi Grady

Janelle Guirguis-Blake, M.D.

William Hyde, M.L.S.

Patrik Johansson, M.D.

Hazel Keimowitz, M.A.

Kristie Kiser

David Lanier, M.D.

Biff LeVee

Kenneth Lin, M.D.

Morgan Liscinsky

Iris Mabry, M.D., M.P.H.

Corey Mackison, M.S.A.

Andrew Marshall

David Meyers, M.D.

Tess Miller, Dr.P.H.

Emily Moser

Kevin Murray

Barbara Najar, M.P.H.
Lisa Nicolella

Nilam Patel, M.P.H.

Amy Pfeiffer

Kathryn Ramage

Gurvaneet Randhawa, M.D., M.P.H.

Eve Shapiro

Randie Siegel, M.S.

Jean Slutsky, P.A., M.S.P.H.

Marion Torchia, M.L.S., M.A.

Tricia Trinité, M.S.P.H., A.P.R.N.

Gloria Washington

Rachel Weinstein

Claire Weschler, M.S.Ed.

Tracy Wolff, M.D., M.P.H.

Evidence-Based Practice Centers

Supporting the USPSTF 2002-2010

The following researchers working through four AHRQ

Evidence-Based Practice Centers prepared systematic

evidence reviews and evidence summaries as resources on

topics under consideration by the USPSTF.

Oregon Evidence-Based Practice Center

Bhaskar Arora, M.D.; Sarah Baird, M.S.; Howard Balshem,

M.S.; Vance Bauer, M.A.; Tracy Beil, M.S.; Ian Blazina,

M.P.H.; Christina Bougatsos, B.S.; David Buckley, M.D.;

Jessica Burnett; Taryn Cardenas, B.S.; Susan Carson,

M.P.H.; Benjamin K.S. Chan, M.S.; Roger Chou, M.D.;

Elizabeth Clark, M.D., M.P.H; Tracy Dana, M.L.S.; Robert

Davis, M.D., M.P.H.; Stephanie Detlefsen, M.D.; Elizabeth

Eckstrom, M.D.; Karen B. Eden, Ph.D.; Michelle Eder,

Ph.D.; Craig Fleming, M.D.; Michele Freeman, M.P.H.;

Rochele Fu, Ph.D.; Betsy Garlitz, M.D.; Nancy Glass,

Ph.D., M.P.H., R.N.; Kenneth Gleitsmann, M.D.; Rachel

Gold, Ph.D., M.P.H; Carla A. Green, Ph.D., M.P.H.; Jessica

Griffin, M.A.; Jeanne-Marie Guise, M.D., M.P.H.; Andrew

Hamilton, M.S., M.L.S.; Elizabeth Haney, M.D; Emily

239

Appendix C
Harris, Ph.D., M.P.H.; Mark Helfand, M.D., M.P.H.;

Theresa Hillier, M.D., M.S.; Rebecca Holmes, M.D., M.S.;

Laurie Huffman, M.S.; Linda Humphrey, M.D., M.P.H.;

Devan Kansagara, M.D.; Tanya Kapka, M.D., M.P.H.; P.

Todd Korthuis, M.D., M.P.H; Kathryn Pyle Krages, M.A.;

Erin Leblanc, M.D., M.P.H.; Beth Liles, M.D.; Jennifer Lin,

M.D.; Kevin W. Lutz, M.F.A.; Yasmin McInerney, M.D.;

Yvonne Michael, Sc.D.; Jill Miller, M.D.; Cynthia D.

Morris, Ph.D., M.P.H.; Arpana Naik, M.D.; Heidi D.

Nelson, M.D., M.P.H.; Rebecca Newton-Thompson, M.D.,

M.Sc.; Susan Norris, M.D., M.P.H.; Peggy Nygren, M.S.;

Michelle Pappas, B.A.; Rita Panosca, M.D.; Kathy Pedula,

M.S.; Leslie Perdue, M.P.H; Daphne Plaut, M.L.S.; Michael

R. Polen, Ph.D.; Elizabeth O’Connor, Ph.D.; Gary

Rischitelli, M.D., J.D., M.P.H.; Cheryl Ritenbaugh, Ph.D.,

M.P.H.; Kevin Rogers, M.D.; Bruin Rugge, M.D., M.P.H.;

Somnath Saha, M.D., M.P.H.; Caitlyn Senger, M.P.H.;

Scott A. Shipman, M.D., M.P.H.; M. E. Beth Smith, D.O.;

Paula R. Smith, R.N., B.S.N.; Ariel K. Smits, M.D.,

M.P.H.; Robert Steiner M.D.; Kelly Streit, M.S., R.D.; Lina

M.A. Takano, M.D., M.S.; Kari Tyne, M.D.; Kimberly

Vesco, M.D., M.P.H.; Kim Villemyer, B.A.; Miranda

Walker, M.A..; Carolyn Westhoff, M.D., M.Sc.; Evelyn P.

Whitlock, M.D., M.P.H.; Selvi B.Williams, M.D., M.P.H.;

Jennifer Wisdom, Ph.D., M.P.H.; Sarah Zuber, M.S.W.

RTI International/University of North Carolina

Evidence-Based Practice Center

Alice Ammerman, Dr.P.H., R.D.; James D. Bader, D.D.S.,

M.P.H.; Rainer Beck, M.D.; John F. Boggess, M.D.; Malaz

Boustani, M.D., M.P.H.; Seth Brody, M.D.; Audrina J.

Bunton; Katrina Donahue, M.D., M.P.H.; Louise

Fernandez, P.A.-C., R.D., M.P.H.; Kenneth Fink, M.D.,

M.G.A., M.P.H.; Carol Ford, M.D.; Angela Fowler-Brown,

M.D.; Bradley N. Gaynes, M.D., M.P.H.; Paul Godley,

M.D., M.P.H.; Susan A. Hall, M.S.; Laura Hanson, M.D.,

240

Appendix C
M.P.H.; Russell Harris, M.D., M.P.H.; Katherine

E.Hartmann, M.D., Ph.D.; Michael Hayden, M.D.; M.

Brian Hemphill, M.D.; Alissa Driscoll Jacobs, M.S., R.D.;

Jana Johnson; Linda Kinsinger, M.D., M.P.H.; Carol

Krasnov; Ramesh Krishnaraj; Carole M. Lannon, M.D.,

M.P.H.; Carmen Lewis, M.D., M.P.H.; Kathleen N. Lohr,

Ph.D.; Linda J. Lux, M.P.A.; Kathleen McTigue, M.D.,

M.P.H.; Catherine Mills, M.A.; Kavita Nanda, M.D.,

M.H.S.; Carla Nester, M.D.; Britt Peterson, M.D., M.P.H.;

Christopher J. Phillips, M.D., M.P.H.; Michael Pignone,

M.D., M.P.H.; Mark Pletcher, M.D., M.P.H.; Saif S.

Rathore; Melissa Rich, M.D.; Gary Rozier, D.D.S.; Jerry L.

Rushton, M.D., M.P.H.; Lucy A. Savitz; Joe Scattoloni;

Stacey Sheridan, M.D., M.P.H.; Sonya Sutton, B.S.P.H.;

Jeffrey A. Tice, M.D.; Suzanne L. West, Ph.D.; B. Lynn

Whitener, Dr.P.H., M.S.L.S.; Margaret Wooddell, M.A.;

Dennis Zolnoun, M.D.

University of Ottawa Evidence-Based Practice Center

Nicholas Barrowman, Ph.D.; Catherine Code, M.D.,

F.R.C.P.C.; Catherine Dubé, M.D., M.Sc., F.R.C.P.C.;

Gabriela Lewin, M.D.; David Moher, Ph.D.; Alaa Rostom,

M.D., M.Sc., F.R.C.P.C.; Margaret Sampson, M.I.L.S.;

Alexander Tsertsvadze, M.D., M.Sc.

Tufts - New England Medical Center Evidence-Based

Practice Center

Priscilla Chew; Mei Chung, M.P.H.; Deirdre DeVine;

Stanley Ip, M.D.; Joseph Lau, M.D.; Gowri Raman, M.D.;

Thomas Trikalinos, M.D., Ph.D.

241

Appendix C
Liaisons to the USPSTF

Primary care partners include:

• American Academy of Family Physicians (AAFP)

• American Academy of Nurse Practitioners (AANP)

• American Academy of Pediatrics (AAP)

• American Academy of Physician Assistants (AAPA)

• American Congress of Obstetricians and Gynecologists

(ACOG)

• American College of Physicians (ACP)

• American College of Preventive Medicine (ACPM)

• American Osteopathic Association (AOA)

• National Association of Pediatric Nurse Practitioners

(NAPNAP)

Policy, population, and quality improvement partners

include:

• America’s Health Insurance Plans (AHIP)

• AARP

• National Committee for Quality Assurance (NCQA)

Federal partners include:

• Centers for Disease Control and Prevention (CDC)

• Centers for Medicare & Medicaid Services (CMS)

• U.S. Food and Drug Administration (FDA)

• Health Resources and Services Administration (HRSA)

• Indian Health Service (IHS)

• National Institutes of Health (NIH)

• Veteran’s Health Administration (VHA)

• Department of Defense/Military Health System

(DoD/MHS)

• Office of Disease Prevention and Health Promotion

(ODPHP)

• Office of the Surgeon General

242

Appendix C
Appendix D

Advisory Committee on Immunization

Practices Recommended Immunization

Schedules

Recommended Immunization Schedule for

Persons Aged 0 Through 6 Years.......................244

Recommended Immunization Schedule for

Persons Aged 7 Through 18 Years.....................250

Catch-up Immunization Schedule for Persons Aged 4

Months Through18 Years Who Start Late

or Are More Than 1 Month Behind.................256

Recommended Adult Immunization Schedule.......262

Figure 1. Recommended adult immunization

schedule, by vaccine and age ............................262

Figure 2. Vaccines that might be indicated for

adults based on medical and other indications...264

243

The USPSTF recognizes the importance of immunizations in primary disease prevention. The Task Force refers

to recommendations made by the Centers for Disease

Control and Prevention’s Advisory Committee on

Immunization Practices (ACIP) for immunization of

children and adults. The methods used by ACIP to review

evidence on immunizations may differ from the methods

used by the USPSTF.
Footnotes begin on page 252.

244
This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the

recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines.

Considerations should include provider assessment, patient preference, and the potential for adverse events.

Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed

recommendations: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that

follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at

http://www.vaers.hhs.gov or by telephone, 800-822-7967.

AppendixD

245
F

o

otnotes

1. Hepatitis B vaccine (HepB). (Minim

u

m age: birth)

At birth:• Administer monovalent HepB to all newborns before hospital discharge.

• If mother is hepatitis B surface antigen (H

BsAg)-positive, administer HepB and 0.5 m

L of hepatitis B

im

mune globulin (H

BIG) within 12 hours of birth.

• If mother’s H

BsAg status is unknown, administer HepB

within 12 hours of birth. Determine mother’s

H

BsAg status as soon as possible and, if H

BsAg-positive, administer H

BIG (no later than age 1 week).

After the birth

dose:

• The HepB series should be completed with either monovalent HepB or a combination vaccine containing

HepB. The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should

be used for doses administered before age 6 weeks. The final dose should be administered no earlier than

age 24 weeks.

• Infants born to H

BsAg-positive mothers should be tested for H

BsAg and antibody to H

BsAg 1 to 2

months after completion of at least 3 doses of the HepB series, at age 9 through 18 months (generally at

the next well-child visit).

• Administration of 4 doses of HepB to infants is permissible when a combination vaccine containing HepB

is administered after the birth dose. The fourth dose should be administered no earlier than age 24 weeks.

246

Appendix D
2. Rotavirus vaccine (RV). (Minim

u

m age: 6 weeks)

• Administer the first dose at age 6 through 14 weeks (maximum age: 14 weeks 6 days). Vaccination should

not be initiated for infants aged 15 weeks 0 days or older.

• The maximum age for the final dose in the series is 8 months 0 days

• If Rotarix® is administered at ages 2 and 4 months, a dose at 6 months is not indicated.

3. Diphtheria an

d tetan

us toxoids an

d acellular pertussis vaccine (D

TaP). (Minim

u

m age: 6 weeks)

• The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed

since the third dose.

• Administer the final dose in the series at age 4 through 6 years.

4. Haemop

hilus influenzae type b conjugate vaccine (Hib). (Minim

u

m age: 6 weeks)

• If PRP-O

MP (PedvaxHIB® or Comvax® [HepB-Hib]) is administered at ages 2 and 4 months, a dose at

age 6 months is not indicated.

• TriHiBit

® (D

TaP/Hib) and Hiberix® (PRP-T) should not be used for doses at ages 2, 4, or 6 months for

the primary series but can be used as the final dose in children aged 12 months through 4 years.

5. P

neu

mococcal vaccine. (Minim

u

m age: 6 weeks for pneu

mococcal conjugate vaccine [P

CV]; 2 years

for pneu

mococcal polysaccharide vaccine [P

PSV])

• PC

V is recom

mended for all children aged younger than 5 years. Administer 1 dose of PC

V to all healthy

children aged 24 through 59 months who are not completely vaccinated for their age.

• Administer PPSV 2 or more months after last dose of PC

V to children aged 2 years or older with certain

underlying medical conditions, including a cochlear implant. See MM

WR 1997;46(No. RR-8).

247

Appendix D
6. Inactivated poliovirus vaccine (IPV) (Minim

u

m age: 6 weeks)

• The final dose in the series should be administered on or after the fourth birthday and at least 6 months

following the previous dose.

• If 4 doses are administered prior to age 4 years a fifth dose should be administered at age 4 through 6

years. See MM

WR 2009;58(30):829–30.

7. Influenza vaccine (seasonal). (Minim

u

m age: 6 months for trivalent inactivated influenza vaccine

[TIV]; 2 years for live, atten

uated influenza vaccine [LAIV])

• Administer annually to children aged 6 months through 18 years.

• For healthy children aged 2 through 6 years (i.e., those who do not have underlying medical conditions

that predispose them to influenza complications), either LAIV or TIV

may be used, except LAIV should

not be given to children aged 2 through 4 years who have had wheezing in the past 12 months.

• Children receiving TIV should receive 0.25 m

L if aged 6 through 35 months or 0.5 m

L if aged 3 years or

older.

• Administer 2 doses (separated by at least 4 weeks) to children aged younger than 9 years who are receiving

influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza

season but only received 1 dose.

• For recom

mendations for use of influenza A (H1N1) 2009 monovalent vaccine see MM

WR 2009;58(No.

RR-10).

8. Measles, m

u

mps, an

d rubella vaccine (M

M

R). (Minim

u

m age: 12 months)

• Administer the second dose routinely at age 4 through 6 years. However, the second dose may be

administered before age 4, provided at least 28 days have elapsed since the first dose.

248

Appendix D
9. Varicella vaccine. (Minim

u

m age: 12 months)

• Administer the second dose routinely at age 4 through 6 years. However, the second dose may be

administered before age 4, provided at least 3 months have elapsed since the first dose.

• For children aged 12 months through 12 years the minimum interval between doses is 3 months.

However, if the second dose was administered at least 28 days after the first dose, it can be accepted as

valid.

10. Hepatitis A vaccine (HepA). (Minim

u

m age: 12 months)

• Administer to all children aged 1 year (i.e., aged 12 through 23 months). Administer 2 doses at least 6

months apart.

• Children not fully vaccinated by age 2 years can be vaccinated at subsequent visits

• HepA also is recom

mended for older children who live in areas where vaccination programs target older

children, who are at increased risk for infection, or for whom im

munity against hepatitis A is desired.

11. Meningococcal vaccine. (Minim

u

m age: 2 years for meningococcal conjugate vaccine [M

CV4] an

d for

meningococcal polysaccharide vaccine [M

PSV4])

• Administer M

C

V4 to children aged 2 through 10 years with persistent complement component

deficiency, anatomic or functional asplenia, and certain other conditions placing tham at high risk.

• Administer M

C

V4 to children previously vaccinated with M

C

V4 or MPSV4 after 3 years if first dose

administered at age 2 through 6 years. See MM

WR 2009; 58:1042–3.

T

he Recom

men

ded Im

m

u

nization Sched

ules for Persons Aged 0 through 18 Years are approved by the

Advisory

Com

mittee on Im

m

u

nization

Practices (http://www.cdc.gov/vaccines/recs/acip), the American

Academy of Pediatrics (http://www.aap.org), an

d the American

Academy of Family

P

hysicians

(http://www.aafp.org).

249

Appendix D
2

50

Footnotes begin on page 258.
2

51

AppendixD

This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the

recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines.

Considerations should include provider assessment, patient preference, and the potential for adverse events.

Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed

recommendations: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that

follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at

http://www.vaers.hhs.gov or by telephone, 800-822-7967.
252

Appendix D

F

o

otnotes

1. Tetan

us an

d

diphtheria toxoids an

d acellular pertussis vaccine (T

dap). (Minim

u

m age: 10 years for

Boostrix® an

d 11 years for Adacel

®)

• Administer at age 11 or 12 years for those who have completed the recom

mended childhood D

TP/D

TaP

vaccination series and have not received a tetanus and diphtheria toxoid (Td) booster dose.

• Persons aged 13 through 18 years who have not received Tdap should receive a dose.

• A 5-year interval from the last Td dose is encouraged when Tdap is used as a booster dose; however, a

shorter interval may be used if pertussis im

munity is needed.

2. H

u

man papillomavirus vaccine (H

PV). (Minim

u

m age: 9 years)

• Two HPV vaccines are licensed: a quadrivalent vaccine (HPV4) for the prevention of cervical, vaginal and

vulvar cancers (in females) and genital warts (in females and males), and a bivalent vaccine (HPV2) for the

prevention of cervical cancers in females.

• HPV vaccines are most effective for both males and females when given before exposure to HPV through

sexual contact.

• HPV4 or HPV2 is recom

mended for the prevention of cervical precancers and cancers in females.

• HPV4 is recom

mended for the prevention of cervical, vaginal and vulvar precancers and cancers and

genital warts in females.

• Administer the first dose to females at age 11 or 12 years.

• Administer the second dose 1 to 2 months after the first dose and the third dose 6 months after the first

dose (at least 24 weeks after the first dose).

• Administer the series to females at age 13 through 18 years if not previously vaccinated.

• HPV4 may be administered in a 3-dose series to males aged 9 through 18 years to reduce their likelihood

of acquiring genital warts.
253

Appendix D

3. Meningococcal conjugate vaccine (M

CV4).

• Administer at age 11 or 12 years, or at age 13 through 18 years if not previously vaccinated.

• Administer to previously unvaccinated college freshmen living in a dormitory.

• Administer M

C

V4 to children aged 2 through 10 years with persistent complement component

deficiency, anatomic or functional asplenia, or certain other conditions placing them at high risk.

• Administer to children previously vaccinated with M

C

V4 or MPSV4 who remain at increased risk

after 3 years (if first dose administered at age 2 through 6 years) or after 5 years (if first dose

administered at age 7 years or older). Persons whose only risk factor is living in on-campus housing are

not recom

mended to receive an additional dose. See MM

WR 2009;58:1042–3.

4. Influenza vaccine (seasonal).

• Administer annually to children aged 6 months through 18 years.

• For healthy nonpregnant persons aged 7 through 18 years (i.e., those who do not have underlying

medical conditions that predispose them to influenza complications), either LAIV or TIV

may be

used.

• Administer 2 doses (separated by at least 4 weeks) to children aged younger than 9 years who are

receiving influenza vaccine for the first time or who were vaccinated for the first time during the

previous influenza season but only received 1 dose.

• For recom

mendations for use of influenza A (H1N1) 2009 monovalent vaccine. See MM

WR

2009;58(No. RR-10).
5. P

neu

mococcal polysaccharide vaccine (P

PSV).

• Administer to children with certain underlying medical conditions, including a cochlear implant. A single

revaccination should be administered after 5 years to children with functional or anatomic asplenia or an

im

munocompromising condition. See MM

WR 1997;46(No. RR-8).

6. Hepatitis A vaccine (HepA).

• Administer 2 doses at least 6 months apart.

• HepA is recom

mended for children aged older than 23 months who live in areas where vaccination

programs target older children, who are at increased risk for infection, or for whom im

munity against

hepatitis A is desired.

7. Hepatitis B vaccine (HepB).

• Administer the 3-dose series to those not previously vaccinated.

• A 2-dose series (separated by at least 4 months) of adult formulation Recombivax H

B is licensed for

children aged 11 through 15 years.

8. Inactivated poliovirus vaccine (IPV).

• The final dose in the series should be administered on or after the fourth birthday and at least 6 months

following the previous dose.

• If both OPV and IPV

were administered as part of a series, a total of 4 doses should be administered,

regardless of the child’s current age.

Appendix D

254
9. Measles, m

u

mps, an

d rubella vaccine (M

M

R).

• If not previously vaccinated, administer 2 doses or the second dose for those who have received only 1

dose, with at least 28 days between doses.

10. Varicella vaccine.

• For persons aged 7 through 18 years without evidence of im

munity (see MM

WR 2007;56[No. RR-4]),

administer 2 doses if not previously vaccinated or the second dose if only 1 dose has been administered.

• For persons aged 7 through 12 years, the minimum interval between doses is 3 months. However, if the

second dose was administered at least 28 days after the first dose, it can be accepted as valid.

• For persons aged 13 years and older, the minimum interval between doses is 28 days. Appendix D

255
256
2

57

Footnotes begin on page 260.
F

o

otnotes

1. Hepatitis B vaccine (HepB).

• Administer the 3-dose series to those not previously vaccinated.

• A 2-dose series (separated by at least 4 months) of adult formulation Recombivax H

B® is licensed for

children aged 11 through 15 years.

2. Rotavirus vaccine (RV).

• The maximum age for the first dose is 14 weeks 6 days. Vaccination should not be initiated for infants

aged 15 weeks 0 days or older.

• The maximum age for the final dose in the series is 8 months 0 days.

• If Rotarix® was administered for the first and second doses, a third dose is not indicated.

3. Diphtheria an

d tetan

us toxoids an

d acellular pertussis vaccine (D

TaP).

• The fifth dose is not necessary if the fourth dose was administered at age 4 years or older.

4. Haemophilus influenzae type b conjugate vaccine (Hib).

• Hib vaccine is not generally recom

mended for persons aged 5 years or older. No efficacy data are available

on which to base a recom

mendation concerning use of Hib vaccine for older children and adults.

However, studies suggest good im

munogenicity in persons who have sickle cell disease, leukemia, or HIV

infection, or who have had a splenectomy; administering 1 dose of Hib vaccine to these persons who have

not previously received Hib vaccine is not contraindicated.

• If the first 2 doses were PRP-O

MP (PedvaxHIB® or Comvax®), and administered at age 11 months or

younger, the third (and final) dose should be administered at age 12 through 15 months and at least 8

weeks after the second dose.

• If the first dose was administered at age 7 through 11 months, administer the second dose at least 4

weeks later and a final dose at age 12 through 15 months.

258

Appendix D
5. P

neu

mococcal vaccine.

• Administer 1 dose of pneumococcal conjugate vaccine (PC

V) to all healthy children aged 24 through 59

months who have not received at least 1 dose of PC

V on or after age 12 months.

• For children aged 24 through 59 months with underlying medical conditions, administer 1 dose of PC

V if

3 doses were received previously or administer 2 doses of PC

V at least 8 weeks apart if fewer than 3 doses

were received previously.

• Administer pneumococcal polysaccharide vaccine (PPSV) to children aged 2 years or older with certain

underlying medical conditions, including a cochlear implant, at least 8 weeks after the last dose of PC

V.

See MM

WR 1997;46(No. RR-8).

6. Inactivated poliovirus vaccine (IPV).

• The final dose in the series should be administered on or after the fourth birthday and at least 6 months

following the previous dose.

• A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6

months following the previous dose.

• In the first 6 months of life, minimum age and minimum intervals are only recom

mended if the person is

at risk for im

minent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an

outbreak).

7. Measles, m

u

mps, an

d rubella vaccine (M

M

R).

• Administer the second dose routinely at age 4 through 6 years. However, the second dose may be administered before age 4, provided at least 28 days have elapsed since the first dose.

• If not previously vaccinated, administer 2 doses with at least 28 days between doses.

259

Appendix D
8. Varicella vaccine.

• Administer the second dose routinely at age 4 through 6 years. However, the second dose may be administered before age 4, provided at least 3 months have elapsed since the first dose.

• For persons aged 12 months through 12 years, the minimum interval between doses is 3 months.

However, if the second dose was administered at least 28 days after the first dose, it can be accepted as

valid.

• For persons aged 13 years and older, the minimum interval between doses is 28 days.

9. Hepatitis A vaccine (HepA).

• HepA is recom

mended for children aged older than 23 months who live in areas where vaccination programs target older children, who are at increased risk for infection, or for whom im

munity against hepatitis A is desired.

10. Tetan

us an

d

diphtheria toxoids vaccine (T

d) an

d tetan

us an

d

diphtheria toxoids an

d acellular pertussis vaccine (T

dap).

• Doses of D

TaP are counted as part of the Td/Tdap series

• Tdap should be substituted for a single dose of Td in the catch-up series or as a booster for children aged

10 through 18 years; use Td for other doses.

260

Appendix D
2

61

AppendixD

11. Human papillomavirus vaccine (HPV).

• Administer the series to females at age 13 through 18 years if not previously vaccinated.

• Use recommended routine dosing intervals for series catch-up (i.e., the second and third doses should be

administered at 1 to 2 and 6 months after the first dose). The minimum interval between the first and second doses is 4 weeks. The minimum interval between the second and third doses is 12 weeks, and the

third dose should be administered at least 24 weeks after the first dose.

Information about reporting reactions after immunization is available online at http://www.vaers.hhs.gov or

by telephone, 800-822-7967. Suspected cases of vaccine-preventable diseases should be reported to the state or

local health department. Additional information, including precautions and contraindications for immunization, is available from the National Center for Immunization and Respiratory Diseases at

http://www.cdc.gov/vaccines or telephone, 800-CDC-INFO (800-232-4636).
NOTE: These recommendations must be read along with the footnotes, available at

http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.

262
Ap

pendixD

Information about reporting reactions after immunization is available online at http://www.vaers.hhs.gov or

by telephone, 800-822-7967. Suspected cases of vaccine-preventable diseases should be reported to the state or

local health department. Additional information, including precautions and contraindications for immunization, is available from the National Center for Immunization and Respiratory Diseases at

http://www.cdc.gov/vaccines or telephone, 800-CDC-INFO (800-232-4636).

263
NOTE: These recommendations must be read along with the footnotes, available at

http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.

264
These schedules indicate the recom

mended age groups and medical indications for which administration of

currently licensed vaccines is com

monly indicated for adults ages 19 years and older, as of January 1, 2010.

Licensed combination vaccines may be used whenever any components of the combination are indicated and

when the vaccine’s other components are not contraindicated. For detailed recom

mendations on all vaccines,

including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Com

mittee on Im

munization Practices

(www.cdc.gov/vaccines/pubs/acip-list.htm).

T

he recom

men

dations in this sched

ule were approved by the Centers for Disease Control an

d

Prevention’s (C

D

C) Advisory

Com

mittee on Im

m

u

nization

Practices (ACIP), the American

Academy of

Family

P

hysicians (AAF

P), the American

College of Obstetricians an

d

Gynecologists (AC

O

G), an

d the

American

College of P

hysicians (AC

P).

Appendix D

265
267

Index

5-A Approach

(see Alcohol Misuse, Screening and Behavioral

Counseling Interventions in Primary Care to

Reduce)

(see Obesity in Adults, Screening for)

AAA (see Abdominal Aortic Aneurysm, Screening for)

Abdominal Aortic Aneurysm, Screening for.........57

Alcohol, Avoidance While Driving (see Motor Vehicle

Occupant Restraints and Avoidance of Alcohol Use

While Driving, Counseling About Proper Use)

Alcohol Misuse, Screening and Behavioral

Counseling Interventions in Primary Care to

Reduce ...........................................................131

Anemia, Iron Deficiency (see Iron Deficiency Anemia,

Screening for—Including Iron Supplementation for

Children and Pregnant Women)

Ankle Brachial Index (see Peripheral Arterial Disease,

Screening for)

Aspirin for the Prevention of Cardiovascular

Disease.............................................................61

Aspirin or Nonsteroidal Anti-inflammatory Drugs

for the Primary Prevention of Colorectal Cancer,

Routine ............................................................13

Asymptomatic Bacteriuria (see Bacteriuria in Adults,

Screening for Asymptomatic)
Index of Recommendations

268

Bacterial Vaginosis in Pregnancy to Prevent

Preterm Delivery, Screening for.....................179

Bacteriuria in Adults, Screening for

Asymptomatic..................................................93

Basal Cell Cancer (see Skin Cancer, Screening for)

Bladder Cancer in Adults, Screening for..............15

Blood Lead Levels in Children and Pregnant

Women, Screening for Elevated.....................195

Blood Pressure, High (see High Blood Pressure,

Screening for)

BMI Screening, Adults (see Obesity in Adults,

Screening for)

BMI Screening, Children and Adolescents (see

Overweight in Children and Adolescents, Screening

and Interventions for)

Bone Density Measurement (see Osteoporosis in

Postmenopausal Women, Screening for)

BRCA Mutation Testing (see Breast and Ovarian

Cancer Susceptibility, Genetic Risk Assessment and

BRCA Mutation Testing for)

Breast and Ovarian Cancer Susceptibility, Genetic

Risk Assessment and BRCA Mutation Testing

for....................................................................16

Breast Cancer, Chemoprevention of.....................20

*Breast Cancer, Screening for.........................21, 28
Index of Recommendations

269

Breast Self Examination [BSE] (see Breast Cancer,

Screening for)

Breastfeeding, Primary Care Interventions

to Promote.....................................................181

CA-125 Screening for Ovarian Cancer (see Breast and

Ovarian Cancer Susceptibility, Genetic Risk

Assessment and BRCA Mutation Testing for)

Cancer

(see Aspirin or Nonsteroidal Anti-inflammatory

Drugs for the Primary Prevention of Colorectal

Cancer, Routine)

(see Bladder Cancer in Adults, Screening for)

(see Breast and Ovarian Cancer Susceptibility,

Genetic Risk Assessment and BRCA Mutation

Testing for)

(see Breast Cancer, Screening for)

(see Cervical Cancer, Screening for)

(see Colorectal Cancer, Screening for)

(see Lung Cancer Screening)

(see Oral Cancer, Screening for)

(see Ovarian Cancer, Screening for)

(see Pancreatic Cancer, Screening for)

(see Prostate Cancer, Screening for)

(see Skin Cancer, Counseling to Prevent)
Index of Recommendations

270

(see Skin Cancer, Screening for)

(see Testicular Cancer, Screening for)

(see Vitamin Supplementation to Prevent Cancer

and Cardiovascular Disease, Routine)

Cancer Prevention, Routine Vitamin

Supplementation (see Vitamin Supplementation to

Prevent Cancer and Cardiovascular Disease,

Routine)

Cardiovascular Disease Prevention, Routine Vitamin

Supplementation (see Vitamin Supplementation to

Prevent Cancer and Cardiovascular Disease,

Routine)

Carotid Artery Stenosis, Screening for .................73

Cervical Cancer, Screening for .............................31

Chest X-Ray (see Lung Cancer Screening)

Chlamydial Infection, Screening for.....................95

Chronic Bilirubin Encephalopathy (see

Hyperbilirubinemia in Infants, Screening to

Prevent Chronic Bilirubin Encephalopathy)

Chronic Obstructive Pulmonary Disease,

Screening for....................................................75

Clinical Breast Examination [CBE] (see Breast Cancer,

Screening for)

Clinical Testicular Examination (see Testicular Cancer,

Screening for)

Colonoscopy (see Colorectal Cancer, Screening for)
Index of Recommendations

271

Colorectal Cancer, Aspirin/NSAIDS (see Aspirin or

Nonsteroidal Anti-inflammatory Drugs for the

Primary Prevention of Colorectal Cancer, Routine)

Colorectal Cancer, Screening for..........................36

Congenital Hypothyroidism, Screening for .......199

Coronary Heart Disease Prevention (see Aspirin for the

Prevention of Cardiovascular Disease)

*Coronary Heart Disease (Risk Assessment,

Nontraditional Risk Factors, Screening for)....80

Coronary Heart Disease, Screening for................77

COPD (see Chronic Obstructive Pulmonary Disease,

Screening for)

*Depression in Adults, Screening for .................136

Depression or Depressive Disorders in Children and

Adolescents (see Major Depressive Disorders in

Children and Adolescents, Screening for)

Developmental Dysplasia of the Hip,

Screening for..................................................201

Diabetes Mellitus in Adults, Screening for

Type 2............................................................171

Diet, Behavioral Counseling in Primary Care to

Promote a Healthy ........................................151

Domestic Violence (see Family and Intimate Partner

Violence, Screening for)

Drug Use, Illicit (see Illicit Drug Use, Screening for)
Drug Abuse (see Illicit Drug Use, Screening for)

Dysplasia, Hip (see Developmental Dysplasia of the

Hip, Screening for)

Electrocardiography [ECG] (see Coronary Heart

Disease, Screening for)

Electron-Beam Computerized Tomography [EBCT]

(see Coronary Heart Disease, Screening for)

Elevated Blood Lead Levels (see Blood Lead Levels in

Children and Pregnant Women, Screening for

Elevated)

Estrogen Therapy (see Hormone Therapy for the

Prevention of Chronic Conditions in

Postmenopausal Women)

Exercise (see Physical Activity, Behavioral Counseling

in Primary Care to Promote)

Exercise Treadmill Test [ETT] (see Coronary Heart

Disease, Screening for)

Family and Intimate Partner Violence,

Screening for..................................................125

Fecal Occult Blood Testing [FOBT] (see Colorectal

Cancer, Screening for)

*Folic Acid to Prevent Neural Tube Defects .......152

Genetic Risk Assessment and BRCA Mutation Testing

(see Breast and Ovarian Cancer Susceptibility,

Genetic risk Assessment and BRCA Mutation

Testing for)

272

Index of Recommendations
Genital Herpes, Screening for...............................99

Gestational Diabetes Mellitus, Screening for .....183

Glaucoma, Screening for ....................................187

Gonococcal Ophthalmia Neonatorum (see Gonorrhea,

Screening for)

Gonorrhea, Screening for ...................................102

Healthy Diet (see Diet, Behavioral Counseling in

Primary Care to Promote a Healthy)

Hearing Loss in Newborns, Universal

Screening for..................................................213

Heart Disease (see Coronary Heart Disease, Screening

for)

Hemochromatosis, Screening for........................154

Hepatitis B Virus Infection, Screening for .........106

*Hepatitis B Virus Infection in Pregnant Women,

Screening for..................................................108

Hepatitis C in Adults, Screening for ..................110

Hereditary Hemochromatosis (see Hemochromatosis,

Screening for)

Herpes Simplex Virus (see Genital Herpes, Screening

for)

High Blood Pressure, Screening for......................84

High Cholesterol (see Lipid Disorders in Adults OR in

Children, Screening for)

273

Index of Recommendations
Hip Dysplasia (see Developmental Dysplasia of the

Hip, Screening for)

HIV, Screening for..............................................112

Hormone Therapy for the Prevention of Chronic

Conditions in Postmenopausal Women ........157

HPV Testing (see Cervical Cancer, Screening for)

HT or HRT (see Hormone Therapy for the Prevention

of Chronic Conditions in Postmenopausal Women)

Human Immunodeficiency Virus (see HIV, Screening

for)

*Hyperbilirubinemia in Infants, Screening

to Prevent Chronic Bilirubin

Encephalopathy .............................................203

Hyperlipidemia in Adults (see Lipid Disorders in

Adults OR in Children, Screening for)

Hypertension (see High Blood Pressure, Screening for)

Hypothyroidism, Congenital (see Congenital

Hypothyroidism, Screening for)

Idiopathic Scoliosis (see Scoliosis in Adolescents,

Screening for Idiopathic)

Illicit Drug Use, Screening for............................143

Intimate Partner Violence (see Family and Intimate

Partner Violence, Screening for)

*Impaired Visual Acuity in Older Adults,

Screening for..................................................190

274

Index of Recommendations
Iron Deficiency Anemia, Screening for—Including

Iron Supplementation for Children and

Pregnant Women ...........................................160

Iron Supplementation (see Iron Deficiency Anemia,

Screening for—Including Iron Supplementation for

Children and Pregnant Women)

Lead Levels in Blood, Elevated (see Blood Lead Levels

in Children and Pregnant Women, Screening for

Elevated)

Lipid Disorders in Adults, Screening for..............86

Lipid Disorders in Children, Screening for........208

Low Dose Computerized Tomography (see Lung

Cancer Screening)

Lung Cancer Screening.........................................41

Major Depressive Disorder in Children and

Adolescents, Screening for.............................211

Major Depressive Disorder in Adults (see Depression

(Adults), Screening for)

Mammography (see Breast Cancer, Screening for)

Melanoma (see Skin Cancer, Screening for)

Motor Vehicle Occupant Restraints and

Avoidance of Alcohol Use While Driving,

Counseling.....................................................128

Neural Tube Defects (see Folic Acid to Prevent Neural

Tube Defects)

275

Index of Recommendations
Newborn Hearing Screening (see Hearing Loss in

Newborns, Universal Screening for)

Non-Steroidal Anti-Inflammatories [NSAIDS] (see

Aspirin or Nonsteroidal Anti-inflammatory Drugs

for the Primary Prevention of Colorectal Cancer,

Routine)

Obesity in Adults, Screening for.........................163

*Obesity in Children and Adolescents,

Screening for..................................................215

Oral Cancer, Screening for ...................................43

Osteoporosis, Screening for................................175

Ovarian Cancer, Screening for..............................45

Overweight (see Obesity in Adults or Obesity in

Children and Adolescents)

Pancreatic Cancer, Screening for ..........................47

Pap Smear (see Cervical Cancer, Screening for)

Peripheral Arterial Disease, Screening for............91

Phenylketonuria, Screening for..........................218

Physical Activity, Behavioral Counseling in

Primary Care to Promote ..............................168

PKU (see Phenylketonuria, Screening for)

Postmenopausal Hormone Therapy (see Hormone

Therapy for the Prevention of Chronic Conditions

in Postmenopausal Women)

276

Index of Recommendations
Progestin Therapy (see Hormone Therapy for the

Prevention of Chronic Conditions in

Postmenopausal Women)

Prostate Cancer, Screening for..............................48

PSA Screening for Prostate Cancer (see Prostate

Cancer, Screening for)

Rh (D) Incompatibility, Screening for ...............185

Scoliosis in Adolescents, Screening for

Idiopathic ......................................................206

Sexually Transmitted Infections, Counseling to

Prevent...........................................................116

Sickle Cell Disease, Screening for.......................219

Sigmoidoscopy (see Colorectal Cancer, Screening for)

Skin Cancer, Counseling to Prevent.....................51

Skin Cancer, Screening for ...................................52

Speech and Language Delay in Preschool Children,

Screening for..................................................221

Squamous Cell Cancer (see Skin Cancer, Screening

for)

Smoking Cessation (see Tobacco Use and TobaccoCaused Disease, Counseling to Prevent or Tobacco

Use and Tobacco-Caused Disease in Adults and

Pregnant Women, Counseling and Interventions to

Prevent)

Spirometry Screening for COPD (see Chronic

Obstructive Pulmonary Disease, Screening for)

277

Index of Recommendations
Sputum Cytology (see Lung Cancer Screening)

STI or STD

(see Sexually Transmitted Infections, Counseling to

Prevent)

(see Chlamydial Infection, Screening for)

(see Gonorrhea, Screening for)

(see Genital Herpes, Screening for)

(see HIV, Screening for)

(see Syphilis Infection, Screening for)

Suicide Risk, Screening for.................................146

Sunscreen (see Skin Cancer, Counseling to Prevent)

Syphilis Infection, Screening for ........................119

*Syphilis Infection in Pregnancy,

Screening for..................................................122

T3 (see Thyroid Disease, Screening for)

T4

(see Thyroid Disease, Screening for)

(see Congenital Hypothyroidism, Screening for)

Testicular Cancer, Screening for...........................54

Thyroid Disease, Screening for...........................169

*Tobacco Use and Tobacco-Caused Disease in

Adults and Pregnant Women, Counseling

and Interventions to Prevent.........................148

278

Index of Recommendations
Tobacco Use and Tobacco-Caused Disease,

Counseling to Prevent ...................................223

TSH

(see Thyroid Disease, Screening for)

(see Congenital Hypothyroidism, Screening for)

Ultrasonography (see Abdominal Aortic Aneurysm,

Screening for)

Ultraviolet [UVA/UVB] Light (see Skin Cancer,

Counseling to Prevent)

Vaginosis, Bacterial (see Bacterial Vaginosis in

Pregnancy, Screening for)

Violence, Domestic (see Family and Intimate Partner

Violence, Screening for)

Visual Impairment in Adults (see Impaired Visual

Acuity in Older Adults, Screening for)

Visual Impairment in Children Younger Than Age 5

Years, Screening for .......................................224

Vitamin Supplementation to Prevent Cancer and

Cardiovascular Disease, Routine .....................56

279

Index of Recommendations
Bringing the prevention information clinicians

need—recommendations, clinical considerations,

and selected practice tools—to the point of care.

The ePSS helps you identify and select screening,

counseling, and preventive medication services

based on specific patient characteristics.

Available at

http://epss.ahrq.gov/

AHRQ’s Electronic Preventive

Services Selector (ePSS)
More Resources on Preventive Services

The AHRQ Prevention and Care Management Program

aims to improve delivery of appropriate clinical preventive

services. The program disseminates the USPSTF

recommendations in multiple formats and facilitates health

care delivery systems’ implementation of evidence-based

preventive services through partnerships, communication,

user-driven tools, and outreach. Among the many tools and

resources, you will find:

• Brochures on staying healthy and on cardiovascular

diseases,

• Fact sheets on cardiovascular diseases,

• Videos on using “I” statements in clinical practice,

• Checklists for staying healthy at age 50+,

• And more, for clinicians, health care systems, and

consumers.

For more information, and to view the materials online, go

to http://www.ahrq.gov/clinic/ppipix.htm.

The Guide to Community Preventive Services provides

recommendations on population-based interventions to

promote health and prevent disease, injury, disability, and

premature death. Recommendations are promulgated by the

Task Force on Community Preventive Services, an

independent group appointed by the Director of the Centers

for Disease Control and Prevention. For information, go to

http://www.thecommunityguide.org.

The National Guideline ClearinghouseTM (NGC) is a

database of evidence-based clinical practice guidelines and

related documents. To access, go to http://www.guideline.gov.
U.S. Department of Health and Human Services

Agency for Healthcare Research and Quality

www.ahrq.gov

AHRQ Pub. No. 10-05145

August 2010

ISBN No. 978-1-58763-397-3

In This Guide...

t Section 1. Preventive Services Recommended

by the USPSTF (P. 1)

t Section 2. Recommendations for Adults (P. 11)

t Cancer (P. 13)

t Heart, Vascular, and Respiratory Diseases (P. 57)

t Infectious Diseases (P. 93)

t Injury and Violence (P. 125)

t Mental Health Conditions and

Substance Abuse (P. 131)

t Metabolic, Nutritional, and Endocrine

Conditions (P. 151)

t Musculoskeletal Conditions (P. 175)

t Obstetric and Gynecologic Conditions (P. 179)

t Vision Disorders (P. 187)

t Section 3. Recommendations for Children

and Adolescents (P. 193)

t Appendixes and Index (P. 227)