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EVIDENCE BASED RECOMMENDATIONS FOR PREVENTIVE SERVICES
CLINICAL SERVICES 
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Clinical Preventive Services

The ACPM and the U.S. Preventive Services Task Force (USPSTF), based at the Agency for Healthcare Research and Quality, have each developed evidence-based recommendations regarding the delivery of clinical preventive services. Click on the topic to see the related recommendations.

Screening ½ Counseling ½ Immunizations and Chemoprophylaxis

Screening

Cardiovascular Diseases
Abdominal Aortic Aneurysm
Asymptomatic Carotid Artery Stenosis
Asymptomatic Coronary Artery Disease
High Blood Cholesterol and Other Lipid Abnormalities
Hypertension
Peripheral Arterial Disease

Congenital Disorders
Congenital Hypothyroidism
Down Syndrome
Hemoglobinopathies
Neural Tube Defects, Including Folic Acid/Folate Prophylaxis
Phenylketonuria

Infectious Diseases
Asymptomatic Bacteriuria
Chlamydial Infection, Including Ocular Prophylaxis in Newborns
Genital Herpes Simplex
Gonorrhea, Including Ocular Prophylaxis in Newborns
Hepatitis B Virus Infection
Human Immunodeficiency Virus Infection
Rubella, Including Immunization of Adolescents and Adults
Syphilis
Tuberculous Infection, Including Bacille Calmette-Guerin Immunization

Mental Disorders and Substance Abuse
Dementia
Depression
Drug Abuse
Family Violence
Problem Drinking
Suicide Risk

Metabolic, Nutritional, and Environmental Disorders
Diabetes Mellitus
Elevated Lead Levels in Childhood and Pregnancy
Iron Deficiency Anemia, Including Iron Prophylaxis
Obesity
Thyroid Disease

Musculoskeletal Disorders
Adolescent Idiopathic Scoliosis
Postmenopausal Osteoporosis

Neoplastic Diseases
Bladder Cancer
Breast Cancer
Cervical Cancer
Colorectal Cancer
Lung Cancer
Oral Cancer
Ovarian Cancer
Pancreatic Cancer
Prostate Cancer
Skin Cancer
Testicular Cancer
Thyroid Cancer

Prenatal Disorders
D (Rh) Incompatibility
Home Uterine Activity Monitoring
Intrapartum Electronic Fetal Monitoring
Preeclampsia
Ultrasonography in Pregnancy

Vision and Hearing Disorders
Glaucoma
Hearing Impairment
Visual Impairment

Counseling

Dental and Periodontal Disease
Gynecologic Cancers
Healthy Diet
HIV Infection, and Other Sexually Transmitted Diseases
Household and Recreational Injuries
Low Back Pain
Motor Vehicle Injuries
Physical Activity
Tobacco Use
Unintended Pregnancy
UV Light Exposure
Youth Violence

Immunizations and Chemoprophylaxis

Adult Immunizations, Including Chemoprophylaxis Against Influenza A
Aspirin Prophylaxis for the Primary Prevention of Myocardial Infarction
Aspirin Prophylaxis in Pregnancy
Childhood Immunizations
Postexposure Prophylaxis for Selected Infectious Diseases
Postmenopausal Hormone Prophylaxis

 

Clinical Preventive Services -
Screening - Cardiovascular Diseases -

Abdominal Aortic Aneurysm

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening of asymptomatic adults for abdominal 
aortic aneurysm with abdominal palpation or ultrasound.


Clinical Preventive Services -
Screening -Cardiovascular Diseases -

Asymptomatic Carotid Artery Stenosis

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against screening asymptomatic persons for carotid artery stenosis 
using the physical examination or carotid ultrasound. For selected high-risk patients, a recommendation to discuss the 
potential benefits of screening and carotid endarterectomy may be made on other grounds. All persons should be 
screened for hypertension and clinicians should provide counseling about smoking cessation.


Clinical Preventive Services -
Screening - Cardiovascular Diseases -

Asymptomatic Coronary Artery Disease

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against screening middle-aged and older men and women for 
asymptomatic coronary artery disease, using resting electrocardiography (ECG), ambulatory ECG, or exercise ECG. 
Recommendations against routine screening can be made on other grounds for individuals who are not at high risk 
of developing clinical heart disease (see Clinical Intervention). Routine screening is not recommended as part of the 
periodic health visit or pre-participation sports examination for children, adolescents, or young adults. Clinicians 
should emphasize proven measures for the primary prevention of coronary disease (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Cardiovascular Diseases -

High Blood Cholesterol and Other
Lipid Abnormalities

U.S. Preventive Services Task Force Recommendations:

Periodic screening for high blood cholesterol is recommended for all men ages 35-65 and women ages 45-65. There is insufficient evidence to recommend for or against routine screening of asymptomatic persons over age 65, but recommendations to screen healthy men and women ages 65-75 may be made on other grounds (see Clinical Intervention). There is also insufficient evidence to recommend for or against routine screening in children, adolescents, or young adults. Recommendations for screening adolescents and young adults with risk factors for coronary disease, and against routine screening in children, may be made on other grounds (see Clinical Intervention). There is insufficient evidence to recommend for or against routine screening for other lipid abnormalities. All patients should receive periodic screening and counseling regarding other measures to reduce their risk of coronary disease (see
Screening for Hypertension;  Counseling to Prevent Tobacco Use;  Counseling to Promote Physical Activity;  and Counseling to Promote a Healthy Diet)
 

 

Clinical Preventive Services -
Screening - Cardiovascular Diseases -

Hypertension

U.S. Preventive Services Task Force Recommendations:

Screening for hypertension is recommended for all children and adults (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Cardiovascular Diseases -

Peripheral Arterial Disease

U.S. Preventive Services Task Force Recommendations:

Routine screening for peripheral arterial disease in asymptomatic persons is not recommended. Clinicians should be alert to symptoms of peripheral arterial disease in persons at increased risk (see Clinical Intervention) and should evaluate patients who have clinical evidence of vascular disease.

 

Clinical Preventive Services -
Screening - Congenital Disorders -

Congenital Hypothyroidism

U.S. Preventive Services Task Force Recommendations:

Screening for congenital hypothyroidism with thyroid function tests on dried-blood spot specimens is recommended for all newborns in the first week of life (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Congenital Disorders -

Down Syndrome

U.S. Preventive Services Task Force Recommendations:

The offering of amniocentesis or chorionic villus sampling (CVS) for chromosome studies is recommended for pregnant women at high risk for Down syndrome. The offering of screening for Down syndrome by serum multiple-marker testing is recommended for all low-risk pregnant women, and as an alternative to amniocentesis and CVS for high-risk women (see Clinical Intervention). This testing should be offered only to women who are seen for prenatal care in locations that have adequate counseling and follow-up services. There is currently insufficient evidence to recommend for or against screening for Down syndrome by individual serum marker testing or ultrasound examination, but recommendations against such screening may be made on other grounds (see Clinical Intervention).

Clinical Preventive Services -
Screening - Congenital Disorders -

Hemoglobinopathies

U.S. Preventive Services Task Force Recommendations:

Neonatal screening for sickle hemoglobinopathies is recommended to identify infants who may benefit from antibiotic prophylaxis to prevent sepsis. Whether screening should be universal or targeted to high-risk groups will depend on the proportion of high-risk individuals in the screening area, the accuracy and efficiency with which infants at risk can be identified, and other characteristics of the screening program. All screening efforts must be accompanied by comprehensive counseling and treatment services. Offering screening for hemoglobinopathies to pregnant women at the first prenatal visit is recommended, especially for those at high risk. There is insufficient evidence to recommend for or against routine screening for hemoglobinopathies in high-risk adolescents and young adults, but recommendations to offer such testing may be made on other grounds (see Clinical Intervention).


Clinical Preventive Services -
Screening - Congenital Disorders -

Neural Tube Defects, Including Folic
Acid/Folate Prophylaxis

U.S. Preventive Services Task Force Recommendations:

The offering of screening for neural tube defects by maternal serum alpha-fetoprotein (MSAFP) measurement is recommended for all pregnant women who are seen for prenatal care in locations that have adequate counseling and follow-up services available (see Clinical Intervetion). Screening with MSAFP may be offered as part of multiple-marker screening (see Screening for Down Syndrome). There is insufficient evidence to recommend for or against the offering of screening for neural tube defects by mid-trimester ultrasound examination to all pregnant women, but recommendations against such screening may be made on other grounds (also see Screening Ultrasonography in Pregnancy). Daily multivitamins with folic acid to reduce the risk of neural tube defects are recommended for all women who are planning or capable of pregnancy (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Congenital Disorders -

Phenylketonuria

U.S. Preventive Services Task Force Recommendations:

Screening for phenylketonuria (PKU) by measurement of phenylalanine level on a dried-blood spot specimen is recommended for all newborns prior to discharge from the nursery. Infants who are tested before 24 hours of age should receive a repeat screening test by 2 weeks of age. There is insufficient evidence to recommend for or against routine prenatal screening for maternal PKU, but recommendations against such screening may be made on other grounds.

 

Clinical Preventive Services -
Screening - Infectious Diseases -

Asymptomatic Bacteriuria

U.S. Preventive Services Task Force Recommendations:

Screening for asymptomatic bacteriuria by urine culture is recommended for all pregnant women (see Clinical Intervention). There is insufficient evidence to recommend for or against routine screening for asymptomatic bacteriuria in diabetic or ambulatory elderly women, but recommendations against such screening may be made on other grounds. Routine screening for asymptomatic bacteriuria in other persons is not recommended.

 

Clinical Preventive Services -
Screening - Infectious Diseases -

Chlamydial Infection, Including Ocular
Prophylaxis in Newborns

U.S. Preventive Services Task Force Recommendations:

Routine screening for Chlamydia trachomatis infection is recommended for all sexually active female adolescents, high-risk pregnant women, and other asymptomatic women at high risk of infection (see Clinical Intervention). There is insufficient evidence to recommend for or against routine screening in asymptomatic men. Recommendations to screen selected high-risk male adolescents may be made on other grounds (see Clinical Intervention). Routine screening is not recommended for the general adult population. See Screening for Gonorrhea for recommendations regarding ocular prophylaxis to prevent ophthalmia neonatorum.


Clinical Preventive Services -
Screening - Infectious Diseases -

Genital Herpes Simplex

U.S. Preventive Services Task Force Recommendations:

Routine screening for genital herpes simplex virus (HSV) infection by viral culture or other tests is not recommended for asymptomatic persons, including asymptomatic pregnant women. There is insufficient evidence to recommend for or against the examination of pregnant women in labor for signs of active genital HSV lesions, although recommendations to do so may be made on other grounds (see Clinical Intervention). See Counseling to Prevent HIV Infection and other Sexually Transmitted Diseases for recommendations on counseling to prevent sexually transmitted diseases.


Clinical Preventive Services -
Screening - Infectious Diseases -

Gonorrhea, Including Ocular
Prophylaxis in Newborns

U.S. Preventive Services Task Force Recommendations:

Routine screening for Neisseria gonorrhoeae is recommended for asymptomatic women at high risk of infection (see Clinical Intervention). All high-risk women should be screened during pregnancy. There is insufficient evidence to recommend for or against screening all pregnant women or screening asymptomatic men. Recommendations to screen selected high-risk young men may be made on other grounds (see Clinical Intervention). Routine screening is not recommended for the general adult population. Ocular antibiotic prophylaxis of all newborn infants is recommended to prevent gonococcal ophthalmia neonatorum.

 

Clinical Preventive Services -
Screening - Infectious Diseases -

Hepatitis B Virus Infection

U.S. Preventive Services Task Force Recommendations:

Screening with hepatitis B surface antigen (HBsAg) to detect active (acute or chronic) hepatitis B virus (HBV) infection is recommended for all pregnant women at their first prenatal visit. The test may be repeated in the third trimester in women who are initially HbsAg negative and who are at increased risk of HBV infection during pregnancy. Routine screening for HBV infection in the general population is not recommended. Certain persons at high risk may be screened to assess eligibility for vaccination (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Infectious Diseases -

Human Immunodeficiency Virus Infection

U.S. Preventive Services Task Force Recommendations:

Clinicians should assess risk factors for human immunodeficiency virus (HIV) infection by obtaining a careful sexual history and inquiring about injection drug use in all patients. Periodic screening for infection with HIV is recommended for all persons at increased risk of infection (see Clinical Intervention). Screening is recommended for all pregnant women at risk for HIV infection, including all women who live in states, counties, or cities with an increased prevalence of HIV infection. There is insufficient evidence to recommend for or against universal screening among low-risk pregnant women in low-prevalence areas, but recommendations to counsel and offer screening to all pregnant women may be made on other grounds (see Clinical Intervention). Screening infants born to high-risk mothers is recommended if the mother's antibody status is not known. All patients should be counseled about effective means to avoid HIV infection (see Counseling to Prevent HIV and Other Sexually Transmitted Diseases).

 

Clinical Preventive Services -
Screening - Infectious Diseases -

Rubella, Including Immunization of
Adolescents and Adults

U.S. Preventive Services Task Force Recommendations:

Routine screening for rubella susceptibility by history of vaccination or by serology is recommended for all women of childbearing age at their first clinical encounter. Susceptible nonpregnant women should be offered rubella vaccination; susceptible pregnant women should be vaccinated immediately after delivery. An equally acceptable alternative for nonpregnant women of childbearing age is to offer vaccination against rubella without screening (see Clinical Intervention). There is insufficient evidence to recommend for or against screening or routine vaccination of young men in settings where large numbers of susceptible young adults of both sexes congregate, such as military bases and colleges. Routine screening or vaccination of other young men, of older men, and of postmenopausal women is not recommended.

 

Clinical Preventive Services -
Screening - Infectious Diseases -

Syphilis

U.S. Preventive Services Task Force Recommendations:

Routine serologic screening for syphilis is recommended for all pregnant women and for persons at increased risk of infection (see Clinical Intervention). See Counseling to Prevent HIV and Other Sexually Transmitted Diseases for recommendations on counseling to prevent sexually transmitted diseases.

 

Clinical Preventive Services -
Screening - Infectious Diseases -

Tuberculous Infection, Including Bacille
Calmette-Guerin Immunization

U.S. Preventive Services Task Force Recommendations:

Screening for tuberculous infection with tuberculin skin testing is recommended for asymptomatic high-risk persons. Bacille Calmette-Guérin (BCG) vaccination should be considered only for selected high-risk individuals (see Clinical Intervention).

 

Clinical Preventive Services - Screening -
Mental Disorders and Substance Abuse -

Dementia

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening for dementia with standardized instruments in asymptomatic persons. Clinicians should remain alert for possible signs of declining cognitive function in older patients and evaluate mental status in patients who have problems performing daily activities (see Clinical Intervention).

 

Clinical Preventive Services - Screening -
Mental Disorders and Substance Abuse -

Depression

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against the routine use of standardized questionnaires to screen for depression in asymptomatic primary care patients. Clinicians should maintain an especially high index of suspicion for depressive symptoms in those persons at increased risk for depression (see Clinical Intervention). Physician education in recognizing and treating affective disorders is recommended (see Screening for Suicide Risk).


Clinical Preventive Services - Screening -
Mental Disorders and Substance Abuse -

Drug Abuse

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening for drug abuse with standardized questionnaires or biologic assays. Including questions about drug use and drug-related problems when taking a history from all adolescent and adult patients may be recommended on other grounds (see Clinical Intervention). All pregnant women should be advised of the potential adverse effects of drug use on the development of the fetus. Clinicians should be alert to signs and symptoms of drug abuse in patients and refer drug abusing patients to specialized treatment facilities where available.

 

Clinical Preventive Services - Screening -
Mental Disorders and Substance Abuse -

Family Violence

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against the use of specific screening instruments to detect family violence, but recommendations to include questions about physical abuse when taking a history from adult patients may be made on other grounds (see Clinical Intervention). Clinicians should be alert to the various presentations of child abuse, spouse and partner abuse, and elder abuse.


Clinical Preventive Services - Screening -
Mental Disorders and Substance Abuse -

Problem Drinking

U.S. Preventive Services Task Force Recommendations:

Screening to detect problem drinking is recommended for all adult and adolescent patients. Screening should involve a careful history of alcohol use and/or the use of standardized screening questionnaires (see Clinical Intervention). Routine measurement of biochemical markers is not recommended in asymptomatic persons. Pregnant women should be advised to limit or cease drinking during pregnancy. Although there is insufficient evidence to prove or disprove harms from light drinking in pregnancy, recommendations that women abstain from alcohol during pregnancy may be made on other grounds (see Clinical Intervention). All persons who use alcohol should be counseled about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking alcohol.

 

Clinical Preventive Services - Screening -
Mental Disorders and Substance Abuse -

Suicide Risk

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening by primary care clinicians to detect suicide risk in asymptomatic persons (see Clinical Intervention). Clinicians should be alert to signs of suicidal ideation in persons with established risk factors. The training of primary care clinicians in recognizing and treating affective disorders is recommended. Clinicians should be alert to signs and symptoms of depression (see Screening for Depression) and should routinely ask patients about their use of alcohol and other drugs (See Screening for Problem Drinking and Screening for Drug Abuse).

 

Clinical Preventive Services - Screening -
Metabolic, Nutritional, and Environmental Disorders -

Diabetes Mellitus

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening for diabetes mellitus in asymptomatic adults. There is also insufficient evidence to recommend for or against universal screening for gestational diabetes. Although the benefit of early detection has not been established for any group, clinicians may decide to screen selected persons at high risk of diabetes on other grounds (see Clinical Intervention). Screening with immune markers to identify persons at risk for developing insulin-dependent diabetes is not recommended in the general population.

 

Clinical Preventive Services - Screening -
Metabolic, Nutritional, and Environmental Disorders -

Elevated Lead Levels in Childhood and Pregnancy

ACPM Recommendations:

Screening for elevated lead levels via venous or capillary blood lead testing should be conducted for children aged 1 year only if they are identified as being at high risk for elevated blood lead levels. Criteria for being at high risk include: receipt of Medicaid or WIC, living in a community with ³ 12% prevalence of BLLs at ³ 10 mdg/dL, living in a community with ³ 27% of homes built before 1950, or meeting one or more high-risk criteria of a lead-screening questionnaire. This questionnaire should include both questions suggested by the CDC in their 1997 guidelines, as well as questions developed for and tailored to specific communities. These questions may pertain to use of home remedies and cosmetics, country of origin, and/or behavioral risk factors. Risk assessment for lead exposure should be performed beginning during prenatal visits and continuing until 6 years of age.

U.S. Preventive Services Task Force Recommendations:
Screening for elevated lead levels by measuring blood lead at least once at age 12 months is recommended for all children at increased risk of lead exposure. All children with identifiable risk factors should be screened, as should all children living in communities in which the prevalence of blood lead levels requiring individual intervention, including residential lead hazard control or chelation therapy, is high or is undefined (see Clinical Intervention). Evidence is currently insufficient to recommend an exact community prevalence below which targeted screening can be substituted for universal screening. Clinicians can seek guidance from their local or state health department. There is insufficient evidence to recommend for or against routine screening for lead exposure in asymptomatic pregnant women, but recommendations against such screening may be made on other grounds. There is also insufficient evidence to recommend for or against counseling families about the primary prevention of lead exposure, but recommendations may be made on other grounds. Recommendations regarding the primary prevention of lead poisoning by population-wide environmental interventions are beyond the scope of this chapter.

 

Clinical Preventive Services - Screening -
Metabolic, Nutritional, and Environmental Disorders -

Iron Deficiency Anemia, Including Iron Prophylaxis

U.S. Preventive Services Task Force Recommendations:

Screening for iron deficiency anemia using hemoglobin or hematocrit is recommended for pregnant women and for high-risk infants. There is insufficient evidence to recommend for or against routine screening for iron deficiency anemia in other asymptomatic persons, but recommendations against screening may be made on other grounds (see Clinical Intervention). Encouraging parents to breastfeed their infants and to include iron-enriched foods in the diet of infants and young children is recommended (see also Counseling to Promote a Healthy Diet). There is currently insufficient evidence to recommend for or against the routine use of iron supplements for healthy infants or pregnant women.

Clinical Preventive Services - Screening -
Metabolic, Nutritional, and Environmental Disorders -

Obesity

U.S. Preventive Services Task Force Recommendations:

Periodic height and weight measurements are recommended for all patients (see Clinical Intervention).

 

Clinical Preventive Services - Screening -
Metabolic, Nutritional, and Environmental Disorders -

Thyroid Disease

U.S. Preventive Services Task Force Recommendations:

Routine screening for thyroid disease with thyroid function tests is not recommended for asymptomatic children or adults. There is insufficient evidence to recommend for or against screening for thyroid disease with thyroid function tests in high-risk patients, but recommendations may be made on other grounds (see Clinical Intervention). Clinicians should remain alert to subtle symptoms and signs of thyroid dysfunction when examining such patients. See also Screening for Congenital Hypothyroidism.

Clinical Preventive Services - Screening -
Musculoskeletal Disorders -

Adolescent Idiopathic Scoliosis

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening of asymptomatic adolescents for idiopathic scoliosis. Clinicians should remain alert for large spinal curvatures when examining adolescents.

 

Clinical Preventive Services - Screening -
Musculoskeletal Disorders -

Postmenopausal Osteoporosis

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening for osteoporosis with bone densitometry in postmenopausal women. Recommendations against routine screening may be made on other grounds (see Clinical Intervention). All postmenopausal women should be counseled about hormone prophylaxis (see Immunizations/Chemoprophylaxis for Postmenopausal Chemoprophylaxis) and be advised of the importance of smoking cessation, regular exercise, and adequate calcium intake (see Counseling to Prevent Tobacco Use, Counseling to Promote Physical Activity, and Counseling to Promote a Healthy Diet). For those high-risk women who would consider estrogen prophylaxis only to prevent osteoporosis, screening may be appropriate to assist treatment decisions (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Neoplastic Diseases -

Bladder Cancer

U.S. Preventive Services Task Force Recommendations:

Routine screening for bladder cancer with urine dipstick, microscopic urinalysis, or urine cytology is not recommended in asymptomatic persons. All patients who smoke tobacco should be routinely counseled to quit smoking (see Counseling to Prevent Tobacco Use).

 

Clinical Preventive Services -
Screening - Neoplastic Diseases -

Breast Cancer

ACPM Recommendations:

Low-risk women (no family history, familial cancer syndrome, or prior cancer)
There is inadequate evidence for or against mammography screening of women under age 50. Women between ages 50 and 69 should have annual or biennial, high-quality, two-view mammography. Women aged 70 or older should continue undergoing mammography screening provided their health status permits breast cancer treatment.

Higher-risk women
Women with a family history of premenopausal breast cancer in a first-degree relative or those with a history of breast and/or gynecologic cancer may warrant more aggressive screening. Women with these histories often begin screening at an earlier age, although there is no direct evidence of effectiveness to support this practice. The future availability of genetic screening may define new recommendations for screening high-risk women.

  • See the entire ACPM recommendation at:

Screening Mammography for Asymptomatic Women. Rebecca L. Ferrini, MD, Elizabeth Mannin, MD, Edith Ramsdell, MD and Linda Hill, MD, FACPM. University of California/California State University General Preventive Medicine Residency Program. Am J Prev Med. September/October

U.S. Preventive Services Task Force Recommendations:

Routine screening for breast cancer every 1-2 years, with mammography alone or mammography and annual clinical breast examination (CBE), is recommended for women aged 50-69. There is insufficient evidence to recommend for or against routine mammography or CBE for women aged 40-49 or aged 70 and older, although recommendations for high-risk women aged 40-49 and healthy women aged >=70 may be made on other grounds (see Clinical Intervention). There is insufficient evidence to recommend for or against the use of screening CBE alone or the teaching of breast self-examination.

 

Clinical Preventive Services –
Screening - Neoplastic Diseases -

Cervical Cancer

ACPM Recommendations:

Screening for cervical cancer by regular Pap tests should be performed in all women who are or have been sexually active, and should be instituted after a woman first engages in sexual intercourse. If the sexual history is unknown or considered unreliable, screening should begin at age 18. At least two initial screening tests should be performed one year apart. For women who have had at least two normal annual smears, the screening interval may then be lengthened at the discretion of the patient and physician after considering the presence of risk factors, but should not exceed three years. Screening may be discontinued at age 65 if the following criteria are met: the woman has been regularly screened, has had two satisfactory smears, and has had no abnormal smears within the previous nine years. For all women over age 65 who have not been previously screened, three normal annual smears should be documented prior to discontinuation of screening. Clinicians should use proper techniques in collecting specimens, should submit them to qualified cytopathologic laboratories for analysis, and should provide appropriate follow up on test results.

  • See the entire ACPM recommendation at:

Cervical Cancer Screening. William M. Marine, MD, FACPM and residents at the University of Colorado Health Service Center. Am J Prev Med. September/October 1996.

U.S. Preventive Services Task Force Recommendations:

Routine screening for cervical cancer with Papanicolaou (Pap) testing is recommended for all women who are or have been sexually active and who have a cervix. Pap smears should begin with the onset of sexual activity and should be repeated at least every 3 years (see Clinical Intervention). There is insufficient evidence to recommend for or against an upper age limit for Pap testing, but recommendations can be made on other grounds to discontinue regular testing after age 65 in women who have had regular previous screenings in which the smears have been consistently normal. There is insufficient evidence to recommend for or against routine screening with cervicography or colposcopy, or for screening for human papilloma virus infection, although recommendations against such screening can be made on other grounds (see Clinical Intervention).

Clinical Preventive Services -
Screening - Neoplastic Diseases -

Colorectal Cancer

U.S. Preventive Services Task Force Recommendations:

Screening for colorectal cancer is recommended for all persons aged 50 and older with annual fecal occult blood testing (FOBT), or sigmoidoscopy (periodicity unspecified), or both (see Clinical Intervention). There is insufficient evidence to determine which of these screening methods is preferable or whether the combination of FOBT and sigmoidoscopy produces greater benefits than does either test alone. There is also insufficient evidence to recommend for or against routine screening with digital rectal examination, barium enema, or colonoscopy, although recommendations against such screening in average-risk persons may be made on other grounds (see Clinical Intervention). Persons with a family history of hereditary syndromes associated with a high risk of colon cancer should be referred for diagnosis and management (see Clinical Intervention).


Clinical Preventive Services -
Screening - Neoplastic Diseases -

Lung Cancer

U.S. Preventive Services Task Force Recommendations:

Routine screening for lung cancer with chest radiography or sputum cytology in asymptomatic persons is not recommended. All patients should be counseled against tobacco use (see Counseling to Prevent Tobacco Use).

 

Clinical Preventive Services -
Screening - Neoplastic Diseases -

Oral Cancer

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening of asymptomatic persons for oral cancer by primary care clinicians. All patients should be counseled to discontinue the use of all forms of tobacco (see Counseling to Prevent Tobacco Use) and to limit consumption of alcohol (see Screening for Problem Drinking). Clinicians should remain alert to signs and symptoms of oral cancer and premalignancy in persons who use tobacco or regularly use alcohol.


Clinical Preventive Services -
Screening - Neoplastic Diseases -

Ovarian Cancer

ACPM Recommendations:

The American College of Preventive Medicine does not currently recommend routine pelvic exams for the detection of ovarian cancer (although pelvic examinations may be performed for diagnostic purposes) or the use of CA 125 or ultrasound to screen asymptomatic women. These same recommendations apply to women with either none or one first degree relative with ovarian cancer. Screening of women with familial cancer syndrome may be appropriate, due to their elevated risk of cancer, but direct evidence of effectiveness is lacking. Clinicians should therefore take a thorough family history regarding breast, ovarian, and other cancers, and women at high risk should be counseled about the benefits and risks of ovarian cancer screening. Until prospective, randomized clinical trials are completed, the American College of Preventive Medicine cannot recommend population-based screening apart from participation in clinical investigations.

  • See the entire ACPM recommendation at:

Screening Asymptomatic Women for Ovarian Cancer. Rebecca L. Ferrini, MD, MPH, University of California/California State University General Preventive Medicine Residency Program. Am J Prev Med. November/December 1997.

U.S. Preventive Services Task Force Recommendations:

Routine screening for ovarian cancer by ultrasound, the measurement of serum tumor markers, or pelvic examination is not recommended. There is insufficient evidence to recommend for or against the screening of asymptomatic women at increased risk of developing ovarian cancer.


Clinical Preventive Services -
Screening - Neoplastic Disesases-

Pancreatic Cancer

U.S. Preventive Services Task Force Recommendations:

Routine screening for pancreatic cancer in asymptomatic persons, using abdominal palpation, ultrasonography, or serologic markers, is not recommended.

 

Clinical Preventive Services -
Screening - Neoplastic Diseases -

Prostate Cancer

ACPM Recommendations:

The American College of Preventive Medicine recommends against routine population screening with digital rectal exams and prostate-specific antigen. Men age 50 or older with a life expectancy of greater than 10 years should be given information about the potential benefits and harms of screening and limits of current evidence and should be allowed to make their own choice about screening, in consultation with their physician, based on personal preferences. Methods and tools for helping patients review this information are available, however, the ACPM recommends further research be conducted in optimizing the process of patient education and informed consent.

  • See the entire ACPM recommendation in:

Screening for Prostate Cancer in American Men. Rebecca L. Ferrini, MD, MPH, University of California/California State University and Steven H. Woolf, MD, FACPM, Medical College of Virginia. Am J Prev Med. July 1998.

U.S. Preventive Services Task Force Recommendations:

Routine screening for prostate cancer with digital rectal examinations, serum tumor markers (e.g., prostate-specific antigen), or transrectal ultrasound is not recommended.

 

Clinical Preventive Services -
Screening - Neoplastic Diseases -

Skin Cancer

ACPM Recommendations:

The American College of Preventive Medicine (ACPM) recommends periodic total cutaneous examinations be performed, targeting populations at high risk for malignant melanoma. The ACPM, however, finds insufficient evidence to characterize periodicity of skin examinations more precisely. Those at high risk include individuals with family or personal history of skin cancer, predisposing phenotypic characteristics, and increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions -- e.g., dysplastic or congenital nevi. The ACPM also recommends that practitioners who perform skin examinations undergo training to assure high-quality examinations and to reduce unnecessary biopsies. Further research efforts, in the form of well-conducted observational, case-controlled studies, or randomized clinical trials, are needed to better elucidate both the interval and the risk-benefit ratio of screening skin examinations for various populations.

  • See the entire ACPM recommendation at:

Screening for Skin Cancer. Rebecca L. Ferrini, MD, MPH, Monica Perlman, MD, MPH and Linda Hill, MD, FACPM, University of California/California State University General Preventive Medicine Residency Program. Am J Prev Med. January 1998.

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against either routine screening for skin cancer by primary care providers or counseling patients to perform periodic skin self-examinations. A recommendation to consider referring patients at substantially increased risk of malignant melanoma to skin cancer specialists for evaluation and surveillance may be made on other grounds (see Clinical Intervention). Counseling patients at increased risk of skin cancer to avoid excess sun exposure is recommended, based on the proven efficacy of risk reduction, although the effectiveness of counseling has not been well established. T here is insufficient evidence to recommend for or against sunscreen use for the primary prevention of skin cancer.

 

Clinical Preventive Services -
Screening - Neoplastic Diseases -

Testicular Cancer

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening of asymptomatic men in the general population for testicular cancer by physician examination or patient self-examination. Recommendations to discuss screening options with selected high-risk patients may be made on other grounds (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Neoplastic Diseases -

Thyroid Cancer

U.S. Preventive Services Task Force Recommendations:

Routine screening for thyroid cancer using neck palpation or ultrasonography is not recommended for asymptomatic children or adults. There is insufficient evidence to recommend for or against screening persons with a history of external head and neck irradiation in infancy or childhood, but recommendations for such screening may be made on other grounds (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Prenatal Disorders -

D (Rh) Incompatibility

U.S. Preventive Services Task Force Recommendations:

D (formerly Rh) blood typing and antibody screening is recommended for all pregnant women at their first prenatal visit. Repeat antibody screening at 24-28 weeks' gestation is recommended for unsensitized D-negative women (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Prenatal Disorders -

Home Uterine Activity Monitoring

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against home uterine activity monitoring (HUAM) in high-risk pregnancies as a screening test for preterm labor, but recommendations against its use may be made on other grounds (see Clinical Intervention). HUAM is not recommended in normal-risk pregnancies.

 

Clinical Preventive Services -
Screening - Prenatal Disorders -

Intrapartum Electronic Fetal Monitoring

U.S. Preventive Services Task Force Recommendations:

Routine electronic fetal monitoring for low-risk women in labor is not recommended. There is insufficient evidence to recommend for or against intrapartum electronic fetal monitoring for high-risk pregnant women (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Prenatal Disorders -

Preeclampsia

U.S. Preventive Services Task Force Recommendations:

Screening for preeclampsia with blood pressure measurement is recommended for all pregnant women at the first prenatal visit and periodically throughout the remainder of pregnancy (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Prenatal Disorders -

Ultrasonography in Pregnancy

U.S. Preventive Services Task Force Recommendations:

Routine third-trimester ultrasound examination of the fetus is not recommended. There is insufficient evidence to recommend for or against routine ultrasound examination in the second trimester in low-risk pregnant women (see Clinical Intervention).

To refer to the Clinical Interventions or view the complete entry for this topic, see the Guide to Clinical Preventive Services: Second Edition (1996).

 

Clinical Preventive Services -
Screening - Vision and Hearing Disorders -

Glaucoma

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine screening for intraocular hypertension or glaucoma by primary care clinicians. Recommendations to refer high-risk patients for evaluation by an eye specialist may be made on other grounds (see Clinical Intervention).

 

Clinical Preventive Services -
Screening - Vision and Hearing Disorders -

Hearing Impairment

U.S. Preventive Services Task Force Recommendations:

Screening older adults for hearing impairment by periodically questioning them about their hearing, counseling them about the availability of hearing aid devices, and making referrals for abnormalities when appropriate, is recommended. There is insufficient evidence to recommend for or against routinely screening older adults for hearing impairment using audiometric testing (see Clinical Intervention). There is also insufficient evidence to recommend for or against routinely screening asymptomatic adolescents and working-age adults for hearing impairment. Recommendations against such screening, except for those exposed to excessive occupational noise levels, may be made on other grounds (see Clinical Intervention). Routine hearing screening of asymptomatic children beyond age 3 years is not recommended. There is insufficient evidence to recommend for or against routine screening of asymptomatic neonates for hearing impairment using evoked otoacoustic emission testing or auditory brainstem response. Recommendations to screen high-risk infants may be made on other grounds (see Clinical Intervention). Clinicians examining infants and young children should remain alert for symptoms or signs of hearing impairment.

 

Clinical Preventive Services -
Screening - Vision and Hearing Disorders -

Visual Impairment

U.S. Preventive Services Task Force Recommendations:

Vision screening to detect amblyopia and strabismus is recommended once for all children prior to entering school, preferably between ages 3 and 4. Clinicians should be alert for signs of ocular misalignment when examining infants and children. Screening for diminished visual acuity with Snellen visual acuity chart is recommended for elderly persons. There is insufficient evidence to recommend for or against screening for diminished visual acuity among other asymptomatic persons, but recommendations against routine screening may be made on other grounds (see Clinical Intervention).

 

Clinical Preventive Services -
Counseling -

Dental and Periodontal Disease

U.S. Preventive Services Task Force Recommendations:

Counseling patients to visit a dental care provider on a regular basis, floss daily, brush their teeth daily with a fluoride-containing toothpaste, and appropriately use fluoride for caries prevention and chemotherapeutic mouth rinses for plaque prevention is recommended based on evidence for risk reduction from these interventions. Educating parents to curb the practice of putting infants and children to bed with a bottle is also recommended based on limited evidence of risk reduction. The effectiveness of clinician counseling to change any of these behaviors has not been adequately evaluated. Appropriate dietary fluoride supplements are recommended for children living in communities with inadequate water fluoridation. While examining the oral cavity, clinicians should be alert for obvious signs of oral disease (see Clinical Intervention). Also see Screening for Oral Cancer, and Counseling to Promote a Healthy Diet.

 

Clinical Preventive Services -
Counseling -

Gynecologic Cancers

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine counseling of women about measures for the primary prevention of gynecologic cancers. Clinicians counseling women about contraceptive practices should include information on the potential benefits of oral contraceptives, barrier contraceptives, and tubal sterilization with respect to specific gynecologic cancers (see Counseling to Prevent Unintended Pregnancy). Clinicians should also promote other practices (maintaining desirable body weight, smoking cessation, and safe sex practices) that may reduce the incidence of certain gynecologic cancers and have other proven health benefits (see Screening for Obesity, Counseling to Prevent Tobacco Use, and Counseling to Prevent HIV and Other Sexually Transmitted Diseases).


Clinical Preventive Services -
Counseling -

Healthy Diet

U.S. Preventive Services Task Force Recommendations:

Counseling adults and children over age 2 to limit dietary intake of fat (especially saturated fat) and cholesterol, maintain caloric balance in their diet, and emphasize foods containing fiber (i.e., fruits, vegetables, grain products) is recommended. There is insufficient evidence to recommend for or against counseling the general population to reduce dietary sodium intake or increase dietary intake of iron, beta-carotene, or other antioxidants to improve health outcomes, but recommendations to reduce sodium intake may be made on other grounds. Women should be encouraged to consume recommended quantities of calcium (see Clinical Intervention). Parents should be encouraged to breastfeed their infants. Providing pregnant women with specific nutritional guidelines to enhance fetal and maternal health is recommended. Although there is insufficient evidence to recommend for or against special assessment of the dietary needs and habits of older adults, recommendations to do so can be made on other grounds. There is insufficient evidence that nutritional counseling by physicians has an advantage over counseling by dietitians or community interventions in changing the dietary habits of patients. See Screening for Iron Deficiency regarding the role of iron during pregnancy and in the diets of newborns and young children and Screening for Neural Tube Defects regarding the use of folic acid by women of childbearing age. See Counseling to Prevent Dental and Periodontal Disease regarding intake of refined sugars and adherent carbohydrates that may affect dental health. Counseling regarding alcohol consumption is discussed in Screening for Problem Drinking.

 

Clinical Preventive Services -
Counseling -

HIV Infection, and other Sexually
Transmitted Diseases

U.S. Preventive Services Task Force Recommendations:

All adolescent and adult patients should be advised about risk factors for human immunodeficiency virus (HIV) infection and other sexually transmitted diseases (STDs), and counseled appropriately about effective measures to reduce the risk of infection (see Clinical Intervention). Counseling should be tailored to the individual risk factors, needs, and abilities of each patient. This recommendation is based on the proven efficacy of risk reduction, although the effectiveness of clinician counseling in the primary care setting is uncertain. Individuals at risk for specific STDs should be offered testing in accordance with recommendations on screening for syphilis, gonorrhea, hepatitis B virus infection, HIV infection, and chlamydial infection (see Screening for Hepatitis B Virus Infection, Screening for Syphilis, Screening for Gonorrhea, Screening for HIV Infection, and Screening for Chlamydial Infection). Injection drug users should be advised about measures to reduce their risk and referred to appropriate treatment facilities (see Screening for Drug Abuse).

 

Clinical Preventive Services -
Counseling -

Household and Recreational Injuries

U.S. Preventive Services Task Force Recommendations:

Periodic counseling of the parents of children on measures to reduce the risk of unintentional household and recreational injuries is recommended. Counseling to prevent household and recreational injuries is also recommended for adolescents and adults based on the proven efficacy of risk reduction, although the effectiveness of counseling these patients to prevent injuries has not been adequately evaluated. Persons with alcohol or drug problems should be identified, counseled, and monitored (see Screening for Problem Drinking and Screening for Drug Abuse). Those who use alcohol or illicit drugs should be warned against engaging in potentially dangerous activities while intoxicated. Counseling elderly patients on specific measures to prevent falls is recommended based on fair evidence that these measures reduce the risk of falls, although the effectiveness of counseling elders to prevent falls has not been adequately evaluated. More intensive individualized multifactorial intervention is recommended for high-risk elderly patients in settings where adequate resources to deliver such services are available. There is insufficient evidence to recommend for or against the use of external hip protectors to prevent fall injuries. Counseling to prevent motor vehicle and pedestrian injuries is discussed in Counseling to Prevent Motor Vehicle Injuries.


Clinical Preventive Services -
Counseling -

Low Back Pain

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against counseling patients to exercise to prevent low back pain, but recommendations for regular physical activity can be made based on other proven benefits (see Counseling to Promote Physical Activity). There is also insufficient evidence to recommend for or against the routine use of educational interventions, mechanical supports, or risk factor modification to prevent low back pain (see Clinical Intervention).

 

Clinical Preventive Services -
Counseling -

Motor Vehicle Injuries

U.S. Preventive Services Task Force Recommendations:

Counseling all patients, and the parents of young patients, to use occupant restraints (lap/shoulder safety belts and child safety seats), to wear helmets when riding motorcycles, and to refrain from driving while under the influence of alcohol or other drugs is recommended (see Clinical Intervention). There is currently insufficient evidence to recommend for or against counseling patients to prevent pedestrian injuries. See Counseling to Prevent Household and Recreational Injuries for recommendations on the prevention of bicycling injuries.

 

 

Clinical Preventive Services -
Counseling -

Physical Activity

U.S. Preventive Services Task Force Recommendations:

Counseling patients to incorporate regular physical activity into their daily routines is recommended to prevent coronary heart disease, hypertension, obesity, and diabetes. This recommendation is based on the proven benefits of regular physical activity; the effectiveness of clinician counseling to promote physical activity is not established (see Clinical Intervention).

 

Clinical Preventive Services -
Counseling -

Tobacco Use

ACPM Recommendations:

Clinicians should provide tobacco use cessation counseling at every clinical encounter. The counseling should be personal, medically oriented, clear, and strong. Nonsmokers may be encouraged to remain abstinent. Patients who use tobacco products may be identified through office and medical record systems, such as including smoking status as part of the vital signs. Or using a stamp on the front of the patient record identifying the patient as a smoker. Tobacco users may be counseled on the health effects of tobacco use, and may receive personal advice and encouragement to quit at every visit. Recommendations regarding NRT may be offered. Specific recommendations include: (1) Tobacco usage history should be obtained at all patient visits, (2) Nonsmokers, especially children and adolescents, should be encouraged not to start, (3) Office and medical record systems to identify patients who use tobacco should be employed, (4) Physicians and other office staff should advise all tobacco users to quit, (5) Physicians and other office staff should identify and assist smokers who are willing to quit, (6) Physicians and other office staff should provide motivational interventions for smokers who are not willing to quit.

  • See the entire ACPM recommendation in:

Tobacco Cessation Counseling. Jane Kattapong, MD, University of Washington Preventive Medicine Residency Program. Am J Prev Med. August 1998

U.S. Preventive Services Task Force Recommendations:

Tobacco cessation counseling on a regular basis is recommended for all persons who use tobacco products. Pregnant women and parents with children living at home also should be counseled on the potentially harmful effects of smoking on fetal and child health. The prescription of nicotine patches or gum is recommended as an adjunct for selected patients. Anti-tobacco messages are recommended for inclusion in health promotion counseling of children, adolescents, and young adults (see Clinical Intervention).

 

Clinical Preventive Services -
Counseling -

Unintended Pregnancy

U.S. Preventive Services Task Force Recommendations:

Periodic counseling about effective contraceptive methods is recommended for all women and men at risk for unintended pregnancy (see Clinical Intervention). Counseling should be based on information from a careful sexual history and should take into account the individual preferences, abilities, and risks of each patient. Sexually active patients should also receive information on measures to prevent sexually transmitted diseases (see Counseling to Prevent HIV and Other STDs).

 

Clinical Preventive Services -
Counseling -

UV Light Exposure

ACPM Recommendations:

Sun avoidance and other sun-protective measures (e.g., clothing, hats, opaque sunscreens) are probably effective in reducing skin cancer and should be recommended. The American College of Preventive Medicine finds insufficient evidence to recommend for or against sunscreen use. Nonmelanoma skin cancers may be reduced with regular, daily sunscreen use. There is insufficient evidence that chemical sunscreens protect against MM and they may, in fact, increase risk.

The American College of Preventive Medicine does not believe the evidence supports discussion of sunscreen and sun protection with every patient. However, the College recommends that physicians remain informed on the issue and be able to discuss sun protection with patients who have questions or who are at particular risk (e.g., family history of melanoma, precursor lesions, or markedly increased sun exposure). For those at high risk, providers should caution against prolonged tanning and sunburn and encourage the use of protective clothing. Because of the importance of preventing sunburn in childhood and the increased UV exposure among children and adolescents, the College recommends discussion of sun protection during routine preventive check-ups. The College also recommends increasing research be undertaken into the association of UV radiation and malignant melanoma, the relative efficacy of sunscreens in reducing UVA exposure, and possible carcinogenic effects of sunscreen components. Finally, the College supports studies on the effectiveness of community-wide health promotion campaigns and/or effective physician counseling strategies to educate the public about UV radiation.

  • See the entire ACPM recommendation at:

Physician Recommendation of Protection from UV Light Exposure. Rebecca L. Ferrini, MD, MPH, Monica Perlman, MD, MPH and Linda Hill, MD, FACPM, University of California/California State University General Preventive Medicine Residency Program. Am J Prev Med. January 1998.


Clinical Preventive Services -
Counseling -

Youth Violence

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against clinician counseling of asymptomatic adolescents and adults to prevent morbidity and mortality from youth violence. Adolescent and adult patients should be screened for problem drinking (see Screening for Problem Drinking). Clinicians should also be alert for symptoms and signs of drug abuse and dependence (see Screening for Drug Abuse), the various presentations of family violence (see Screening for Family Violence), and suicidal ideation in persons with established risk factors (see Screening for Suicide Risk).

Clinical Preventive Services -
Immunizations and Chemoprophylaxis -

Adult Immunizations, Including
Chemoprophylaxis Against Influenza A

ACPM Recommendations:

Adults aged 18 years of age and older without contraindications should receive immunizations for influenza, pneumococcal disease, hepatitis B, tetanus-diphtheria, and measles-mumps-rubella as outlined in the ACIP's Update on Adult Immunization (Table 1). Priorities should include efforts to improve provider and public awareness of the safety and efficacy of adult vaccination; to avoid missed opportunities for vaccination, such as visits to health care providers for other problems, entry into school or employment situations, or travel; to use reminder systems for patients and providers; to have adequate supplies of vaccine; to improve mechanisms for financing and delivery of vaccine; and to assure support for research on better vaccines. Individuals with special risk factors might require additional immunizations.

  • See the entire ACPM recommendation in:

Adult Immunizations. Ann R. Fingar, MD, MPH and Byron J. Francis, MD, FACPM, Illinois Department of Public Health. Am J Prev Med. February 1998.

U.S. Preventive Services Task Force Recommendations:

Annual influenza vaccine is recommended for all persons aged 65 and older and persons in selected high-risk groups (see Clinical Intervention). Pneumococcal vaccine is recommended for all immunocompetent individuals who are age 65 years and older or otherwise at increased risk for pneumococcal disease (see Clinical Intervention). There is insufficient evidence to recommend for or against pneumococcal vaccine for high-risk immunocompromised individuals, but recommendations for vaccinating these persons may be made on other grounds. The series of combined tetanus-diphtheria toxoids (Td) should be completed for adults who have not received the primary series, and all adults should receive periodic Td boosters. Vaccination against measles and mumps should be provided to all adults born after 1956 who lack evidence of immunity. A second measles vaccination is recommended for adolescents and young adults in settings where such individuals congregate (e.g., high schools and colleges). See Screening for Rubella for recommendations for rubella vaccine. Hepatitis B vaccine is recommended for all young adults not previously immunized and for all persons at high risk for infection (see Clinical Intervention). Hepatitis A vaccine is recommended for persons at high risk for hepatitis A virus (HAV) infection (see Clinical Intervention). Varicella vaccine is recommended for susceptible adults (see also Chapter 65). See Screening for Tuberculosis Infection for recommendations regarding the Bacille Calmette-Guérin (BCG) vaccine. Recommendations for postexposure prophylaxis against selected infectious diseases are in Chapter 67; see also Chapter 24, Screening for Hepatitis B Virus Infection.

 

Clinical Preventive Services -
Immunizations and Chemoprophylaxis -

Aspirin Prophylaxis for the Primary
Prevention of Myocardial Infarction

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against routine aspirin prophylaxis for the primary prevention of myocardial infarction (MI) in asymptomatic persons. Although aspirin reduces the risk of MI in men ages 40-84, its use is associated with important adverse effects, and the balance of benefits and harms is uncertain. If aspirin prophylaxis is considered, clinicians and patients should discuss potential benefits and risks for the individual before beginning its use (see Clinical Intervention).

 

Clinical Preventive Services -
Immunizations and Chemoprophylaxis -

Aspirin Prophylaxis in Pregnancy

U.S. Preventive Services Task Force Recommendations:

There is insufficient evidence to recommend for or against the routine use of aspirin to prevent preeclampsia or intrauterine growth retardation in pregnant women, including those at high risk (see Clinical Intervention).

 

Clinical Preventive Services -
Immunizations and Chemoprophylaxis -

Childhood Immunizations

ACPM Recommendations:

All children without established contraindications should receive DTP, DTaP, MMR, Hib, hepatitis B, varicella, and OPV or IPV vaccinations as outlined in the Unified Schedule of Childhood Immunizations and as detailed in the ACIP's General Recommendations on Immunization. Children with special risk factors, such as compromised immune systems or residence in high-risk areas, may require additional immunizations. Furthermore, all health care providers should adopt the 18 standards of immunization practice to work toward the Childhood Immunization Initiative goal of 90% vaccination rate of 2 year olds. Research priorities include the development of new vaccines for disease as well as improvement of immunogenicity and minimizing of the adverse effects of existing vaccines. Moreover, investigating new combinations of vaccines will help to minimize the emotional and physical trauma and inefficiency of multiple injections in children while promoting compliance.

  • See the entire ACPM recommendation at:

Childhood Immunizations. Linda Kinsinger, MD, FACPM and Rita Patel, MD, University of North Carolina Preventive Medicine Residency Program. Am J Prev Med. March/April 1997.

U.S. Preventive Services Task Force Recommendations:

All children without established contraindications should receive diphtheria-tetanus-pertussis (DTP), oral poliovirus (OPV), measles-mumps-rubella (MMR), conjugate Haemophilus influenzae type b, hepatitis B, and varicella vaccines, in accordance with recommended schedules (see Clinical Intervention). Hepatitis A vaccine is recommended for children and adolescents at high risk for hepatitis A virus (HAV) infection. Pneumococcal vaccine and annual influenza vaccine are recommended for children and adolescents at high risk (see Clinical Intervention and Immunizations/Chemoprophylaxis for Adult Immunizations). See the recommendations in Immunizations/Chemoprophylaxis for Postexposure Prophylaxis for Selected Infectious Diseases, and Screening for Tuberculosis Infection for recommendations regarding the Bacille Calmette-Guérin (BCG) vaccine.

 

Clinical Preventive Services -
Immunizations and Chemoprophylaxis -

Postexposure Prophylaxis for
Selected Infectious Diseases

U.S. Preventive Services Task Force Recommendations:

Postexposure prophylaxis should be provided to selected persons with exposure or possible exposure to Haemophilus influenzae type b, hepatitis A, hepatitis B, meningococcal, rabies, or tetanus pathogens (see Clinical Intervention). See the recommendations in Immunizations/Chemoprophylaxis for Postexposure Prophylaxis against Influenza A.

 

Clinical Preventive Services -
Immunizations and Chemoprophylaxis -

Postmenopausal Hormone Prophylaxis

ACPM Recommendations:

There is insufficient evidence to make a generalized recommendation for or against Hormone Replacement Therapy (HRT) use by all menopausal women. Physicians should consistently address the potential risks and benefits of HRT with all perimenopausal female patients and arrive at a decision compatible with the patient’s risk-factor profile and subjective preferences. Once a decision is reached to start HRT, estrogen alone is recommended in women of post-hysterectomy status, while combination therapy with estrogen and progesterone is recommended in women with an intact uterus. Women with coronary risk factors (hypertension, lipid abnormalities, and/or family history of heart disease) may benefit from HRT even if they have a family history of breast cancer. However, modification of cardiac risk factors by alternative means can also be considered in this group. The results of HERS suggest that HRT should be avoided or used cautiously in women with known coronary disease; whether this pertains to estrogen alone, or exclusively to the combination of estrogen and progesterone, remains to be elucidated. For patients with a personal history of breast cancer and/or thromboembolic disease, alternative means of reducing risk for osteoporosis and cardiovascular disease should be considered. The importance of adhering to recommended screening protocols for breast cancer should be stressed. The role of newer synthetic estrogens has not yet been adequately studied, but preliminary evidence is favorable. Such agents may be particularly appropriate in women who have cardiac or osteoporosis risk factors, but are unwilling to accept the breast cancer risk associated with conventional HRT. Current evidence favors indefinite use of HRT once initiated, but the risks of therapy over a period of decades have not been well studied. The decision to use HRT should be revisited at regular intervals in the light of both new data from randomized trials and the patient’s response to therapy.

  • See the entire ACPM recommendation in:

Counseling on Hormone Replacement for Peri and Postmenopausal Women, David Katz, MD and Haq Nawaz, MD, Griffin Hospital, Connecticut. Am J Prev Med. October 1999.

U.S. Preventive Services Task Force Recommendations:

Counseling all perimenopausal and postmenopausal women about the potential benefits and risks of hormone prophylaxis is recommended. There is insufficient evidence to recommend for or against hormone therapy for all postmenopausal women. Women should participate fully in the decision-making process, and individual decisions should be based on patient risk factors for disease, clear understanding of the probable benefits and risks of hormone therapy, and patient preferences (see Clinical Intervention).