Section 2. Recommendations for Adults (continued)

Guide to Clinical Preventive Services, 2014

All clinical summaries in this Guide are abridged recommendations. To see the full recommendation statements and recommendations published after March 2014, go to http://www.uspreventiveservicestaskforce.org.

 Genital Herpes

Title Screening for Genital Herpes
Population Asymptomatic pregnant women Asymptomatic adolescents and adults
Recommendation Do not screen for herpes simplex virus.
Grade: D
Do not screen for herpes simplex virus.
Grade: D
Screening Tests Methods 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.
Interventions There 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 Harms The 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 Recommendations The 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/.

Gestational Diabetes Mellitus

Title Screening for Gestational Diabetes Mellitus
Population Asymptomatic pregnant women after 24 weeks of gestation Asymptomatic pregnant women before 24 weeks of gestation
Recommendation Screen for gestational diabetes mellitus (GDM).
Grade: B
No recommendation.
Grade: I statement
Risk Assessment Risk factors that increase a woman's risk for developing GDM include obesity, increased maternal age, history of GDM, family history of diabetes, and belonging to an ethnic group with increased risk for type 2 diabetes mellitus (Hispanic, Native American, South or East Asian, African American, or Pacific Islands descent).
Screening Tests There are 2 strategies used to screen for gestational diabetes in the United States. In the 2-step approach, the 50-g oral glucose challenge test is administered between 24 and 28 weeks of gestation in a nonfasting state. If the screening threshold is met or exceeded (7.22 mmol/L [130 mg/dL], 7.50 mmol/L [135 mg/dL], or 7.77 mmol/L [140 mg/dL]), patients receive the oral glucose tolerance test. A diagnosis of GDM is made when 2 or more glucose levels meet or exceed the specified glucose thresholds. In the 1-step approach, a 75-g glucose load is administered after fasting and plasma glucose levels are evaluated after 1 and 2 hours. GDM is diagnosed if 1 glucose value falls at or above the specified glucose threshold.

Other methods of screening include fasting plasma glucose and screening based on risk factors. However, there is limited evidence about these alternative screening approaches.

Treatment Initial treatment includes moderate physical activity, dietary changes, support from diabetes educators and nutritionists, and glucose monitoring. If the patient's glucose is not controlled after these initial interventions, she may be prescribed medication (either insulin or oral hypoglycemic agents), have increased surveillance in prenatal care, and have changes in delivery management.
Balance of Benefits and Harms There is a moderate net benefit to screening for GDM after 24 weeks of gestation to reduce maternal and fetal complications. The evidence for screening for GDM before 24 weeks of gestation is insufficient, and the balance of benefits and harms of screening cannot be determined.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for type 2 diabetes mellitus. 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/.

 Glaucoma

Title Screening for Glaucoma
Population Adults without vision symptoms who are seen in primary care
Recommendation No recommendation.
Grade: I statement
Risk Assessment Important risk factors for open-angle glaucoma are increased intraocular pressure, older age, family history of glaucoma, and African American race.
Screening Tests Diagnosis of glaucoma is usually made on the basis of several tests that, when combined, evaluate the biologic structure and function of the optic nerve and intraocular pressure. Most tests that are available in a primary care setting do not have acceptable accuracy to detect glaucoma.
Treatment The immediate physiologic goal and measure of effect of primary treatment of glaucoma is reduction in intraocular pressure. Treatments that are effective in reducing intraocular pressure include medications, laser therapy, and surgery. However, these treatments have potential harms, and their effectiveness in reducing patient-perceived impairment in vision-related function is uncertain.
Balance of Benefits and Harms Evidence on the accuracy of screening tests, especially in primary care settings, and the benefits of screening or treatment to delay or prevent visual impairment or improve quality of life is inadequate. Therefore, the overall certainty of the evidence is low, and the USPSTF is unable to determine the balance of benefits and harms of screening for glaucoma in asymptomatic adults.
Other Relevant USPSTF Recommendations The 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/.

Gonorrhea

Title Screening for Gonorrhea
Population Sexually active women, including those who are pregnant, who are at increased risk for infection Men who are at increased risk for infection Men and women who are at low risk for infection Pregnant women who are not at increased risk for infection
Recommendation Screen for gonorrhea.
Grade: B
No recommendation.
Grade: I
(Insufficient Evidence)
Do not screen for gonorrhea.
Grade
No recommendation.
Grade: I
(Insufficient Evidence)
Risk Assessment Women 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 Tests Vaginal 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 Screening Screening 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.
Interventions Genital 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 Harms The 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 Recommendations The 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/.

Healthful Diet and Physical Activity

Title Behavioral Counseling Interventions to Promote A Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults
Population General adult population without a known diagnosis of hypertension, diabetes, hyperlipidemia, or cardiovascular disease
Recommendation Although the correlation among healthful diet, physical activity, and the incidence of cardiovascular disease is strong, existing evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small. Clinicians may choose to selectively counsel patients rather than incorporate counseling into the care of all adults in the general population.

Considerations: Issues to consider include other risk factors for cardiovascular disease, patient readiness for change, social support and community resources that support behavioral change, and other health care and preventive service priorities.

Potential Harms: Harms may include the lost opportunity to provide other services with a greater health effect.

Grade: C

Risk Assessment If an individual's risk for cardiovascular disease is uncertain, there are several calculators and models available to quantify a person's 10-year risk for cardiac events, such as the Framingham-based Adult Treatment Panel III calculator (available at http://hp2010.nhlbihin.net/atpiii/calculator.asp). Generally, persons with a 10-year risk greater than 20% are considered to be high-risk, those with a 10-year risk less than 10% are considered to be low-risk, and those in the 10% to 20% range are considered to be intermediate-risk.
Interventions Medium- or high-intensity behavioral interventions to promote a healthful diet and physical activity may be provided to individual patients in primary care settings or in other sectors of the health care system after referral from a primary care clinician. In addition, clinicians may offer healthful diet and physical activity interventions by referring the patient to community-based organizations. Strong linkages between the primary care setting and community-based resources may improve the delivery of these services.
Balance of Harms and Benefits The USPSTF concludes with moderate certainty that medium- or high-intensity primary care behavioral counseling interventions to promote a healthful diet and physical activity have a small net benefit in adult patients without cardiovascular disease, hypertension, hyperlipidemia, or diabetes.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for carotid artery stenosis, coronary heart disease, high blood pressure, lipid disorders, peripheral arterial disease, and obesity. 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/.

Hearing Loss in Older Adults

Title Screening for Hearing Loss in Older Adults
Population Asymptomatic adults aged 50 years or older
Recommendation No recommendation.
Grade: I (Insufficient Evidence)
Risk Assessment Increasing age is the most important risk factor for hearing loss. Other risk factors include a history of exposure to loud noises or ototoxic agents, including occupational exposures, previous recurrent inner ear infections, genetic factors, and certain systemic diseases, such as diabetes.
Screening Tests Various screening tests are used in primary care settings to detect hearing loss in adults, including:
  • Whispered voice test
  • Finger rub test
  • Watch tick test
  • Single-item screening (for example, asking "Do you have difficulty with your hearing?")
  • Multiple-item patient questionnaire (for example, Hearing Handicap Inventory for the Elderly–Screening Version)
  • Handheld audiometer
Interventions Hearing aids can improve self-reported hearing, communication, and social functioning for some adults with age-related hearing loss.
Balance of Harms and Benefits There is inadequate evidence to determine the balance of benefits and harms of screening for hearing loss in adults aged 50 years or older.

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/.

Hemochromatosis

Title Screening for Hemochromatosis
Population Asymptomatic general population
Recommendation Do not screen for hereditary hemochromatosis.
Grade: D
Risk Assessment Clinically 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 Tests Genetic 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.
Interventions Therapeutic 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 Recommendations The 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/.

Hepatitis B Virus Infection (Pregnant Women)

Title Screening for Hepatitis B Virus Infection (Pregnant Women)
Population All pregnant women
Recommendation Screen 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.

Implementation Establish systems for timely transfer of maternal HBsAg test results to the labor and delivery and newborn medical records.
Other Relevant USPSTF Recommendations USPSTF 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/.

Hepatitis C Virus Infection

Title Screening for Hepatitis C Virus in Adults
Population Persons at high risk for infection and adults born between 1945 and 1965
Recommendation Screen for hepatitis C virus (HCV) infection.
Grade: B
Risk Assessment The most important risk factor for HCV infection is past or current injection drug use. Additional risk factors include receiving a blood transfusion before 1992, long-term hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures.

Adults born between 1945 and 1965 are more likely to be diagnosed with HCV infection, either because they received a blood transfusion before the introduction of screening in 1992 or because they have a history of other risk factors for exposure decades earlier.

Screening Tests Anti–HCV antibody testing followed by confirmatory polymerase chain reaction testing accurately identifies patients with chronic HCV infection. Various noninvasive tests with good diagnostic accuracy are possible alternatives to liver biopsy for diagnosing fibrosis or cirrhosis.
Screening Interval Persons with continued risk for HCV infection (such as injection drug users) should be screened periodically. Evidence on how often screening should occur in these persons is lacking. Adults born between 1945 and 1965 and persons who are at risk because of potential exposure before universal blood screening need only be screened once.
Treatment Antiviral treatment prevents long-term health complications of HCV infection (such as cirrhosis, liver failure, and hepatocellular carcinoma).

The combination of pegylated interferon (α-2a or α-2b) and ribavirin is the standard treatment for HCV infection. In 2011, the U.S. Food and Drug Administration approved the protease inhibitors boceprevir and telaprevir for the treatment of HCV genotype 1 infection (the predominant genotype in the United States).

Balance of Benefits and Harms On the basis of the accuracy of HCV antibody testing and the availability of effective interventions for persons with HCV infection, the USPSTF concludes that there is a moderate net benefit to screening in populations at high risk for infection. The USPSTF concludes that there is also a moderate net benefit to 1-time screening in all adults in the United States born between 1945 and 1965.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for hepatitis B virus infection in adolescents, adults, and 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/.

High Blood Pressure in Adults

Title Screening for High Blood Pressure in Adults
Population Adult general population1
Recommendation Screen 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/.

HIV Infection

Title Screening for HIV
Population Adolescents and adults aged 15 to 65 years, younger adolescents and older adults at increased risk for infection, and pregnant women
Recommendation Screen for HIV infection.
Grade: A
Risk Assessment Men who have sex with men and active injection drug users are at very high risk for new HIV infection. Other persons at high risk include those who have acquired or request testing for other sexually transmitted infections.

Behavioral risk factors for HIV infection include:

  • Having unprotected vaginal or anal intercourse
  • Having sexual partners who are HIV-infected, bisexual, or injection drug users
  • Exchanging sex for drugs or money

The USPSTF recognizes that the above categories are not mutually exclusive, the degree of sexual risk is on a continuum, and individuals may not be aware of their sexual partners' risk factors for HIV infection.

Screening Tests The conventional serum test for diagnosing HIV infection is repeatedly reactive immunoassay, followed by confirmatory Western blot or immunofluorescent assay. Conventional HIV test results are available within 1 to 2 days from most commercial laboratories.

Rapid HIV testing may use either blood or oral fluid specimens and can provide results in 5 to 40 minutes; however, initial positive results require confirmation with conventional methods.

Other U.S. Food and Drug Administration–approved tests for detection and confirmation of HIV infection include combination tests (for p24 antigen and HIV antibodies) and qualitative HIV-1 RNA.

Interventions At present, there is no cure for chronic HIV infection. However, appropriately timed interventions in HIV-positive persons can reduce risks for clinical progression, complications or death from the disease, and disease transmission. Effective interventions include antiretroviral therapy (ART) (specifically, the use of combined ART), immunizations, and prophylaxis for opportunistic infections.
Balance of Benefits and Harms The net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on behavioral counseling to prevent sexually transmitted infections. 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/.

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Current as of June 2014
Internet Citation: Section 2. Recommendations for Adults (continued): Guide to Clinical Preventive Services, 2014. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2b.html