Section 2. Recommendations for Adults (continued)

Guide to Clinical Preventive Services, 2012

All clinical summaries in this Guide are abridged recommendations. To see the full recommendation statements and recommendations published after March 2012, go to http://www.uspreventiveservicestaskforce.org.

 

Screening for Genital Herpes

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAsymptomatic pregnant womenAsymptomatic adolescents and adults
RecommendationDo not screen for herpes simplex virus.
Grade: D
Do not screen for herpes simplex virus.
Grade: D
Screening TestsMethods for detecting herpes simplex virus include viral culture, polymerase chain reaction, and antibody-based tests, such as the western blot assay and type-specific glycoprotein G serological tests.
InterventionsThere is limited evidence that the use of antiviral therapy in women with a history of recurrent infection, or performance of cesarean delivery in women with active herpes lesions at the time of delivery, decreases neonatal herpes infection. There is also limited evidence of the safety of antiviral therapy in pregnant women and neonates.Antiviral therapy improves health outcomes in symptomatic persons (e.g., those with multiple recurrences); however, here is no evidence that the use of antiviral therapy improves health outcomes in those with asymptomatic infection. There are multiple efficacious regimens that may be used to prevent the recurrence of clinical genital herpes.
Balance of Benefits and HarmsThe potential harms of screening asymptomatic pregnant women include false-positive test results, labeling, and anxiety, as well as false-negative tests and false reassurance, although these potential harms are not well studied. The USPSTF determined that there are no benefits associated with screening, and therefore the potential harms outweigh the benefits.The potential harms of screening asymptomatic adolescents and adults include false-positive test results, labeling, and anxiety, although these potential harms are not well studied. The USPSTF determined the benefits of screening are minimal, at best, and the potential harms outweigh the potential benefits.
Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for chlamydia, gonorrhea, HIV, and several other sexually transmitted infections. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for Gestational Diabetes Mellitus

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationPregnant women who have not previously been diagnosed with diabetes
RecommendationNo recommendation.
Grade: I (Insufficient Evidence1).
Risk AssessmentWomen at increased risk of developing gestational diabetes mellitus (GDM) include those who:
  • Are obese.
  • Are older than 25 years.
  • Have a family history of diabetes.
  • Have a history of GDM.
  • Are of certain ethnic groups (Hispanic, American Indian, Asian, or African-American).
Balance of Benefits and HarmsThe current evidence is insufficient to assess the balance between the benefits and harms of screening women for GDM either before or after 24 weeks gestation. Harms of screening include short-term anxiety in some women with positive screening results, and inconvenience to many women and medical practices because most positive screening tests are likely false-positives.
Suggestions for PracticeUntil there is better evidence, clinicians should discuss screening for GDM with their patients and make case-by-case decisions. The discussion should include information about the uncertain benefits and harms as well as the frequency and uncertain meaning of a positive screening test result.
Screening Tests

If a decision is made to screen for GDM:

The screening test most commonly used in the United States is an initial 50-gram 1-hour glucose challenge test (GCT). If the result on the GCT is abnormal, 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.

Screening IntervalsMost screening is conducted between 24 and 28 weeks gestation. There is little evidence about the value of earlier screening.
Other Approaches to PreventionNearly all pregnant women should be encouraged to:
  • Achieve moderate weight gain based on their pre-pregnancy body mass index.
  • Participate in physical activity.

1 The current evidence is insufficient to establish the balance of benefits and harms for screening for gestational diabetes mellitus, either before or after 24 weeks gestation.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for Glaucoma

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAsymptomatic adults
RecommendationNo recommendation.
Grade: I (Insufficient Evidence)
Risk AssessmentThe primary risk factor for developing primary open-angle glaucoma (POAG) is increased intraocular pressure. Other important risk factors are family history, older age, and being of African American descent. Additional risk factors may include decreased central cornea thickness, low diastolic perfusion pressure, diabetes, and severe myopia
Screening Tests

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, along with a loss of visual field sensitivity.

Perimetry assesses visual field loss by mapping a patient's response to visual stimuli presented in various locations within the visual field. Perimetry may be performed by manual or automated methods.

Several consistent perimetry measurements are needed to establish the presence of defects.

Dilated opthalmoscopy or slit lamp examinations are used by specialists to examine changes in the optic disc; however, there is wide variability in its reliability for detecting glaucomatous optic disc progression

InterventionsThe primary treatments for POAG reduce intraocular pressure; these include medications, laser therapy, or surgery. These treatments can effectively reduce the development and progression of small visual field defects. However, their effectiveness 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.
Balance of Benefits and HarmsBecause of the uncertainty of the magnitude of benefit from early treatment and given the known harms of screening and early treatment, the USPSTF could not determine the balance between the benefits and harms of screening for glaucoma.
Other Relevant USPSTF RecommendationsThe USPSTF has also made a recommendation on screening for impaired visual acuity in older adults. This recommendation is available at http://www.uspreventiveservicestaskforce.org/.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for Gonorrhea

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationSexually active women, including those who are pregnant, who are at increased risk for infectionMen who are at increased risk for infectionMen and women who are at low risk for infectionPregnant women who are not at increased risk for infection
RecommendationScreen for gonorrhea.
Grade: B
No recommendation.
Grade: I
(Insufficient Evidence)
Do not screen for gonorrhea.
Grade
No recommendation.
Grade: I
(Insufficient Evidence)
Risk AssessmentWomen and men younger than age 25 years—including sexually active adolescents—are at highest risk for 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
Screening TestsVaginal culture is an accurate screening test when transport conditions are suitable. Newer screening tests, including nucleic acid amplification and 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.
Timing of ScreeningScreening is recommended at the first prenatal visit for pregnant women who are in a high-risk group for gonorrhea infection. For pregnant women 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.
InterventionsGenital gonorrhea infection in men and women, including pregnant women, may be treated with a third-generation cephalosporin. Because of increased prevalence of resistant organisms, fluoroquinolones should not be used to treat gonorrhea. Current guidelines for treating gonorrhea infection are available from the Centers for Disease Control and Prevention (http://www.cdc.gov/std/treatment).
Balance of Benefits and HarmsThe USPSTF concluded that the benefits of screening women at increased risk for gonorrhea infection outweigh the potential harms.The USPSTF could not determine the balance of benefits and harms of screening for gonorrhea in men at increased risk for infection.Given the low prevalence of gonorrhea infection in the general population, the USPSTF concluded that the potential harms of screening in low-prevalence populations outweigh the benefits.The USPSTF could not determine the balance between the benefits and harms of screening for gonorrhea in pregnant women who are not at increased risk for infection.
Other Relevant USPSTF RecommendationsThe USPSTF has also made a recommendation on ocular prophylaxis in newborns for gonococcal ophthalmia neonatorum. This recommendation is available at http://www.uspreventiveservicestaskforce.org/.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for Hemochromatosis

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAsymptomatic general population
RecommendationDo not screen for hereditary hemochromatosis.
Grade: D
Risk AssessmentClinically recognized hereditary hemochromatosis is primarily associated with mutations on the hemochromatosis (HFE) gene. Although this is a relatively common mutation in the U.S. population, only a small subset will develop symptoms of hemochromatosis. An even smaller proportion of these individuals will develop advanced stages of clinical disease.
Screening TestsGenetic screening for HFE mutations can accurately identify individuals at risk for hereditary hemochromatosis. However, identifying an individual with the genotypic predisposition does not accurately predict the future risk for disease manifestation.
InterventionsTherapeutic phlebotomy is the main treatment for hereditary hemochromatosis. Phlebotomy is generally thought to have few side effects.
Balance of Benefits and Harms
  • Screening could lead to identification of a large number of individuals who possess the high-risk genotype but may never manifest the clinical disease. This may result in unnecessary surveillance and diagnostic procedures, labeling, anxiety, and, potentially, unnecessary treatments.
  • There is poor evidence that early therapeutic phlebotomy improves morbidity and mortality in individuals with screening-detected versus clinically-detected hemochromatosis.
  • The USPSTF concluded that the potential harms of genetic screening for hereditary hemochromatosis outweigh the potential benefits.
Other Relevant USPSTF RecommendationsThe USPSTF has also made recommendations on genetic testing for mutations in the breast cancer susceptibility gene to predict breast and ovarian cancer susceptibility. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for Hepatitis B Virus Infection

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationGeneral asymptomatic population
RecommendationDo not screen for hepatitis B virus (HBV) infection.
Grade: D
Risk AssessmentThe main risk factors for HBV infection include diagnosis with a sexually transmitted disease, intravenous drug use, sexual contact with multiple partners, male homosexual activity, and household contact with chronically infected persons. However, screening strategies to identify individuals at high risk have poor predictive value, since 30–40 percent of infected individuals do not have any easily identifiable risk factors.
Screening TestsRoutine screening of the general population for HBV infection is not recommended.
InterventionsRoutine 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.
Balance of Benefits and HarmsThe USPSTF found no evidence that screening the general population for HBV infection improves long-term health outcomes such as cirrhosis, hepatocellular carcinoma, or mortality. The prevalence of HBV infection is low; the majority of infected individuals do not develop chronic infection, cirrhosis, or HBV-related liver disease. Potential harms of screening include labeling, although there is limited evidence to determine the magnitude of this harm. As a result, the USPSTF concluded that the potential harms of screening for HBV infection in the general population are likely to exceed any potential benefits.
Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for hepatitis B infection in pregnant women and screening for hepatitis C virus infection. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for Hepatitis B Virus Infection in Pregnancy

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAll pregnant women
RecommendationScreen for hepatitis B virus (HBV) at the first prenatal visit.
Grade: A
Screening Tests

Serologic identification of hepatitis B surface antigen (HBsAg).

Reported sensitivity and specificity are greater than 98%.

Timing of Screening

Order HBsAg testing at the first prenatal visit.

Re-screen women with unknown HBsAg status or new or continuing risk factors at admission to hospital, birth center, or other delivery setting.

Interventions

Administer hepatitis B vaccine and hepatitis B immune globulin to HBV-exposed infants within 12 hours of birth.

Refer women who test positive for counseling and medical management.
Counseling should include information about how to prevent transmission to sexual partners and household contacts.

Reassure patients that breastfeeding is safe for infants who receive appropriate prophylaxis.

ImplementationEstablish systems for timely transfer of maternal HBsAg test results to the labor and delivery and newborn medical records.
Other Relevant USPSTF RecommendationsUSPSTF recommendations on the screening of pregnant women for other infections, including asymptomatic bacteriuria, bacterial vaginosis, chlamydia, HIV, and syphilis, can be found at http://www.uspreventiveservicestaskforce.org/.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for Hepatitis C Virus in Adults

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAsymptomatic adults who are not at increased risk for infectionAdults who are at high risk for infection
RecommendationDo not screen for hepatitis C virus (HCV) infection.
Grade: D
No recommendation.
Grade: I Statement (Insufficient Evidence)
Risk AssessmentEstablished risk factors for HCV infection include current or past intravenous drug use, receiving a blood transfusion before 1990, dialysis, and being a child of an HCV-infected mother. Surrogate markers, such as high-risk 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.
Screening TestsInitial testing for HCV infection is typically done by enzyme immunoassay.
InterventionsAlthough there is good evidence that antiviral therapy improves intermediate outcomes, such as viremia, there is limited evidence that such treatment improves long-term health outcomes. The current treatment regimen is long and costly and is associated with a high patient dropout rate due to adverse effects. As of 2004, there was insufficient evidence that newer treatment regimens for HCV infection, such as pegylated interferon plus ribavirin, improve long-term health outcomes.
Balance of Benefits and Harms

The prevalence of HCV infection in the general population is low, and most who are infected do not develop cirrhosis or other major negative health outcomes. There is no evidence that screening for HCV infection leads to improved long-term health outcomes, such as decreased cirrhosis, hepatocellular cancer, or mortality. Potential harms of screening include unnecessary biopsies and labeling, although there is limited evidence to determine the magnitude of these harms.

As a result, the USPSTF concluded that the potential harms of screening for HCV infection in adults who are not at increased risk for HCV infection are likely to exceed the potential benefits.

The USPSTF found no evidence that screening for HCV infection in adults at high risk leads to improved long-term health outcomes. The proportion of persons infected with HCV who progress to liver disease is uncertain. Potential harms of screening and treatment include labeling, adverse treatment effects, and unnecessary biopsies, although there is limited evidence to determine the magnitude of these harms.

As a result, the USPSTF could not determine the balance of benefits and harms of screening for HCV infection in adults at increased risk for infection

Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for hepatitis C virus infection in the general population and in pregnant women. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for High Blood Pressure in Adults

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAdult general population1
RecommendationScreen for high blood pressure
Grade: A
Screening Tests

High blood pressure (hypertension) is usually defined in adults as: systolic blood pressure (SBP) of 140 mm Hg or higher, or diastolic blood pressure (DBP) of 90 mm Hg or higher.

Due to 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.

Screening Intervals

The optimal interval for screening adults for hypertension is not known.

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends:

  • Screening every 2 years with BP <120/80.
  • Screening every year with SBP of 120-139 mmHg or DBP of 80-90 mmHg.
Treatment

A variety of pharmacological agents are available to treat hypertension. JNC 7 guidelines for treatment of hypertension can be accessed at http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm.

The following non-pharmacological therapies are associated with reductions in blood pressure:

  • Reduction of dietary sodium intake.
  • Potassium supplementation.
  • Increased physical activity, weight loss.
  • Stress management.
  • Reduction of alcohol intake.
Other Relevant USPSTF Recommendations

Adults with hypertension should be screened for diabetes.

Adults should be screened for hyperlipidemia (depending on age, sex, risk factors) and smoking. Clinicians should discuss aspirin chemoprevention with patients at increased risk for cardiovascular disease.

These recommendations and related evidence are available at http://www.uspreventiveservicestaskforce.org.

1 This recommendation applies to adults without known hypertension.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Screening for HIV

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAdolescents and adults at increased risk for HIV infectionAdolescents and adults who are not at increased risk for HIV infectionPregnant women
RecommendationScreen for HIV.
Grade: A
No recommendation for or against screening.
Grade: C
Screen for HIV.
Grade: A
Risk Assessment

A person is considered at increased risk for HIV infection if he/she reports one or more individual risk factors or receives health care in a high-prevalence or high-risk clinical setting.

High-risk settings include sexually transmitted infection (STI) clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STIs. High-prevalence settings are defined as those known to have a 1% or greater prevalence of infection among the patient population being served.

Individual risk for HIV infection is assessed through a careful patient history. Individuals at increased risk include:

  • Men who have had sex with men after 1975.
  • Persons having unprotected sex with multiple partners.
  • Persons who are past or present injection drug users.
  • Persons who exchange sex for money or drugs or have sex partners who do.
  • Persons whose past or present sex partners are HIV-infected, bisexual, or injection drug users.
  • Persons being treated for sexually transmitted diseases.
  • Persons with a history of blood transfusion between 1978 and 1985.
  • Persons who request an HIV test despite reporting no risk factors (since this group is likely to include individuals not willing to disclose high risk behaviors).
Screening TestsThe standard test for diagnosing HIV infection is the repeatedly reactive enzyme immunoassay, followed by confirmatory western blot or immunofluorescent assay. 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.
Interventions

Evidence supports the benefit of identifying and treating asymptomatic individuals in immunologically advanced stages of HIV disease (i.e., CD4 cell counts <200 cells/mm3) with highly active antiretroviral therapy (HAART). Appropriate 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 (i.e., CD4 cell count<350 cells/mm3 or viral load >100,000 copies/mL.

Recommended regimens of HAART are acceptable to pregnant women and lead to significantly reduced rates of mother-to-child transmission. Early detection of maternal HIV infection also allows for discussion of elective cesarean section and avoidance of breastfeeding, both of which are associated with lower HIV transmission rates.

Balance of Benefits and Harms

The USPSTF found good evidence that screening accurately detects HIV infection and that appropriately timed interventions, particularly HAART, lead to improved health outcomes for many of those screened. False-positive test results are rare, and most adverse events associated with treatment, including metabolic disturbances with an increased risk for cardiovascular events, may be ameliorated by changes in regimen.

The USPSTF concluded that the benefits of screening individuals at increased risk substantially outweigh potential harms.

The USPSTF found fair evidence that screening individuals who are not known to be at increased risk for HIV can detect additional individuals with HIV, and good evidence that appropriately timed interventions lead to improved health outcomes for some of these individuals. However, the yield of screening persons without risk factors would be low, and there are potential harms of screening.

The USPSTF concluded that the benefit of screening individuals without risk factors for HIV is too small relative to the potential harms to justify a general recommendation.

The USPSTF found good evidence that screening accurately detects HIV infection in pregnant women, and fair evidence that prenatal counseling and voluntary testing increases the proportion of HIV-infected women who are diagnosed and treated before delivery. There is no evidence of fetal anomalies or other clinically important fetal harm associated with currently recommended antiretroviral regimens (except for efavirenz). Serious or fatal maternal events are rare using currently recommended combination therapies.

The USPSTF concluded that the benefits of screening all pregnant women substantially outweigh the potential harms.

Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening and counseling for other sexually transmitted infections. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

 

Menopausal Replacement Therapy for the Primary Prevention of Chronic Conditions

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationPostmenopausal womenPostmenopausal women who have had a hysterectomy
RecommendationDo not prescribe combined estrogen and progestin for the prevention of chronic conditions.
Grade: D
Do not prescribe estrogen for the prevention of chronic conditions.
Grade: D
Risk AssessmentThis recommendation applies to the average-risk population. Risk factors for a specific chronic disease or individual characteristics that affect the likelihood of a specific therapy-associated adverse event may cause a woman's net balance of benefits and harms to differ from that of the average population.
Preventive Medications

Although combined estrogen and progestin therapy (specifically, oral conjugated equine estrogen, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d) decreases the risk for fractures in postmenopausal women, there is an accompanying increased risk for serious adverse events, such as stroke, invasive breast cancer, dementia, gallbladder disease, deep venous thrombosis, and pulmonary embolism.

Estrogen therapy (specifically, oral conjugated equine estrogen, 0.625 mg/d) decreases the risk for fractures and has a small effect on the risk for invasive breast cancer, but it is also associated with important harms, such as an increased likelihood of stroke, deep venous thrombosis, and gallbladder disease.

Neither combined estrogen and progestin therapy nor estrogen alone reduces the risk for coronary heart disease in postmenopausal women.

Balance of Benefits and HarmsThe chronic disease prevention benefits of combined estrogen and progestin do not outweigh the harms in most postmenopausal women.The chronic disease prevention benefits of estrogen are unlikely to outweigh the harms in most postmenopausal women who have had a hysterectomy.
Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for osteoporosis and the use of preventive medications for breast cancer, as well as other relevant interventions for the primary or secondary prevention of chronic diseases in women, such as medications for cardiovascular disease and screening for coronary heart disease, high blood pressure, lipid disorders, colorectal cancer, breast cancer, and dementia. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Current as of October 2011
Internet Citation: Section 2. Recommendations for Adults (continued): Guide to Clinical Preventive Services, 2012. October 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2b.html