Prevención en salud

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Actualizado: 10/01/2013

Summary of recommendations for clinical preventive services.

American Academy of Family Physicians (AAFP). Summary of recommendations for clinical preventive services. Leawood (KS): American Academy of Family Physicians (AAFP); 2012 Oct. 19 p.

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Family Physicians (AAFP). Summary of recommendations for clinical preventive services. Leawood (KS): American Academy of Family Physicians (AAFP); 2012 May. 18 p.

General health

To provide recommendations for a broad range of clinical preventive services, including screening, counseling, and preventive medications

  • General Population: Persons who are asymptomatic and not known to be at any increased risk except based on their gender, age, or for specific parameters that apply to substantial groups within the general population
  • Specific Populations: Persons whose health behaviors, living environment, medical history, or factors other than gender or age place them at high risk

Note: These guidelines are not intended for patients who have signs and/or symptoms relating to a particular condition.

Note from the National Guideline Clearinghouse (NGC): Due to insufficient evidence, not all interventions listed below are recommended. See the original guideline document for more information.

Clinical Preventive Services, Including Screening, Counseling, and Immunization

  1. Screening specified populations for abdominal aortic aneurysm
  2. Screening and counseling specified populations regarding alcohol misuse
  3. Screening specified populations for asymptomatic bacteriuria
  4. Screening pregnant women for bacterial vaginosis
  5. Screening adults for bladder cancer
  6. Screening women for breast cancer with mammography, clinical breast examination, digital mammography, or magnetic resonance imaging (MRI)
  7. Teaching routine breast self-examination (BSE)
  8. Referring specified female population for genetic counseling and evaluation for breast cancer susceptibility gene (BRCA) testing
  9. Counseling regarding use of breast cancer prevention medications
  10. Interventions to support and promote breastfeeding
  11. Using aspirin in specified populations to prevent cardiovascular disease
  12. Screening general adult population for asymptomatic carotid artery stenosis (CAS)
  13. Screening women for cervical cancer with cytology (Pap smear), alone or in conjunction with human papillomavirus (HPV) testing
  14. Screening specified populations for chlamydia
  15. Screening for chronic obstructive pulmonary disease (COPD) using spirometry
  16. Screening specified populations for colorectal cancer using fecal occult blood testing, sigmoidoscopy, colonoscopy, computed tomography colonography, or fecal deoxyribonucleic acid (DNA) testing
  17. Using aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer in average risk individuals
  18. Screening newborns for congenital hypothyroidism (CH)
  19. Screening for coronary heart disease with resting or exercise electrocardiography or nontraditional risk factors
  20. Screening specific populations for dementia
  21. Providing fluoride supplementation to prevent dental caries in specified populations
  22. Screening specified populations for depression
  23. Screening for gestational diabetes
  24. Screening specified populations for type 2 diabetes
  25. Screening infants for dysplasia of the hip
  26. Screening for family violence and intimate partner violence
  27. Exercise or physical therapy and vitamin D supplementation for specified populations at risk for falls
  28. Multifactorial risk assessment for specified populations at risk for falls
  29. Serological screening for genital herpes simplex virus infection
  30. Screening adults for glaucoma
  31. Ocular prophylaxis for gonococcal infection in neonates
  32. Screening specified populations for gonorrhea
  33. Counseling on the relationship between a healthful diet and exercise and cardiovascular disease
  34. Behavioral dietary counseling for specified populations
  35. Screening and counseling specified population regarding hearing difficulties
  36. Screening newborns for sensorineural hearing loss (SNHL)
  37. Screening for hereditary hemochromatosis
  38. Screening specified populations for hepatitis B virus (HBV)
  39. Screening specified populations for hepatitis C virus (HCV)
  40. Screening specified populations for human immunodeficiency virus (HIV) infection
  41. Hormone replacement therapy in postmenopausal women
  42. Screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy
  43. Screening specified populations for hypertension
  44. Screening specified populations for illicit drug use
  45. Immunizing identified populations according to American Academy of Family Physicians (AAFP) recommendations
  46. Use of immune marker screening for insulin dependent diabetes mellitus in asymptomatic persons
  47. Screening specified populations for iron deficiency anemia
  48. Screening specified populations for lead poisoning
  49. Screening specified populations for lipid disorders
  50. Using interventions to prevent low back pain
  51. Screening for lung cancer with low-dose computed tomography, x-ray, sputum cytology, or combination of these tests
  52. Counseling regarding motor vehicle occupant restraints
  53. Counseling regarding reducing driving while under the influence of alcohol
  54. Folic acid supplementation in specified female population to prevent neural tube defects
  55. Screening, counseling, and behavioral interventions for obesity
  56. Screening for oral cancer
  57. Screening specified populations for osteoporosis
  58. Screening specified populations for ovarian cancer
  59. Screening for pancreatic cancer using abdominal palpation, ultrasonography, or serological markers
  60. Screening for peripheral arterial disease (PAD)
  61. Screening neonates for phenylketonuria
  62. Screening for prostate cancer
  63. Rh (D) blood typing and antibody testing for pregnant women
  64. Screening adolescents for idiopathic scoliosis
  65. Counseling regarding second-hand smoke
  66. Behavioral counseling to prevent sexually transmitted infections (STIs) in specified populations
  67. Screening newborns for sickle cell disease
  68. Screening and behavioral counseling for skin cancer
  69. Screening preschool children for speech and language delay
  70. Screening for suicide risk
  71. Screening specified populations for syphilis
  72. Screening for testicular cancer
  73. Screening for thyroid cancer using ultrasound
  74. Screening for thyroid disease
  75. Screening specified populations for tobacco use and providing smoking cessation counseling
  76. Screening specified populations for visual difficulties and impairment
  77. Vitamin supplementation (A, C, E, beta-carotene; multivitamins with folic acid; or antioxidant combinations) for prevention of cancer or cardiovascular disease

In 2007, the U.S. Preventive Services Task Force (USPSTF) changed the grading of evidence for new recommendations issued (http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm). Therefore, the American Academy of Family Physicians (AAFP) has also changed its grading of the evidence to be more consistent with the USPSTF. The USPSTF and AAFP are in a transition period and are implementing the use of two different grading systems for the recommendations. The first grading system applies to the recommendations that occurred before May 2007, and the second grading system applies to recommendations that occurred during or after May 2007. These grading systems are outlined in the “Rating Scheme for the Strength of the Recommendations” field.

The starting point for the recommendations is the rigorous analysis of scientific knowledge available as presented by the U.S. Preventive Services Task Force (USPSTF) (http://www.ahrq.gov/CLINIC/uspstfix.htm). The USPSTF conducts impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications.

The Commission on Health of the Public and Science (CHPS) reviews recommendations released by the USPSTF and makes recommendations to the American Academy of Family Physicians (AAFP) Board of Directors. In most cases the AAFP agrees with the USPSTF; however, there are circumstances where there are differences.

The American Academy of Family Physicians (AAFP) grading system for the recommendations that occurred during or after May 2007 includes:

A Recommendation: The AAFP recommends the service. There is high certainty that the net benefit is substantial.

B Recommendation: The AAFP recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

C Recommendation: The AAFP recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.

D Recommendation: The AAFP recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

I Recommendation: The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

I-HB Healthy Behavior is identified as desirable but the effectiveness of physician’s advice and counseling is uncertain.

The AAFP grading system for those recommendations before May 2007 includes:

SR Strongly Recommend: Good quality evidence exists which demonstrates substantial net benefit over harm; the intervention is perceived to be cost effective and acceptable to nearly all patients.

R Recommend: Although evidence exists which demonstrates net benefit, either the benefit is only moderate in magnitude or the evidence supporting a substantial benefit is only fair. The intervention is perceived to be cost effective and acceptable to most patients.

NR No Recommendation Either For or Against: Either good or fair evidence exists of at least a small net benefit. Cost-effectiveness may not be known or patients may be divided about acceptability of the intervention.

RA Recommend Against: Good or fair evidence which demonstrates no net benefit over harm.

I Insufficient Evidence to Recommend Either For or Against: No evidence of even fair quality exists or the existing evidence is conflicting.

I-HB Healthy Behavior is identified as desirable but the effectiveness of physician’s advice and counseling is uncertain.

A formal cost analysis was not performed and published cost analyses were not reviewed.

The American Academy of Family Physicians (AAFP) Summary of Recommendations for Clinical Preventive Services (RCPS) is a document that is periodically updated through the work of the AAFP’s Commission on Health of the Public and Science (CHPS) and is approved by the AAFP Board of Directors.

The rating scheme for the strength of the recommendation for or against a preventive intervention follows the “Major Recommendations” field.

Note from the National Guideline Clearinghouse (NGC): The following recommendations were current as of October 2012. However, because the American Academy of Family Physicians (AAFP) updates their guidance frequently, users may wish to consult the AAFP Web site for the most recent version of the “Summary of Recommendations for Clinical Preventive Services.”

Summary of Recommendations for Clinical Preventive Services

Abdominal Aortic Aneurysm

The AAFP recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 years who have ever smoked. (2005) (Grade: B recommendation) (Grade Definition) (Clinical Consideration)

The AAFP makes no recommendation for or against screening for AAA in men aged 65 to 75 years who have never smoked. (2005) (Grade: C recommendation) (Grade Definition) (Clinical Consideration)

The AAFP recommends against routine screening for AAA in women. (2005) (Grade: D recommendation) (Grade Definition) (Clinical Consideration)

Alcohol Misuse

The AAFP recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. (2004) (Grade: B recommendation) (Grade Definition) (Clinical Consideration)

The AAFP recognizes avoidance of alcohol products by adolescents is desirable. The effectiveness of physician’s advice and counseling in this area is uncertain. (2004) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

Bacteriuria, Asymptomatic

The AAFP recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks’ gestation or at the first prenatal visit, if later. (2008) (Grade: A recommendation) (Grade Definition) (Clinical Consideration)

The AAFP recommends against screening for asymptomatic bacteriuria in men and nonpregnant women. (2008) (Grade: D recommendation) (Grade Definition) (Clinical Consideration)

Bacterial Vaginosis

The AAFP recommends against screening for bacterial vaginosis in asymptomatic pregnant women at low risk for preterm delivery. (2008) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in asymptomatic pregnant women at high risk for preterm delivery. (2008) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Bladder Cancer

The AAFP concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults. (August 2011) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Breast Cancer

Family physicians should discuss with each woman the potential benefits and harms of breast cancer screening tests and develop a plan for early detection of breast cancer that minimizes potential harms. These discussions should include the evidence regarding each screening test, the risk of breast cancer, and individual patient preferences. The recommendations below are based on current best evidence as summarized by the U.S. Preventive Services Task Force (USPSTF) and can help to guide physicians and patients. These recommendations are intended to apply to women who are not at increased risk of developing breast cancer and only apply to routine screening procedures.

The AAFP recommends that the decision to conduct screening mammography before age 50 should be individualized and take into account patient context including her risks as well as her values regarding specific benefits and harms. (January 2010) (Grade: C recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends biennial (every two years) screening mammography for women between ages 50 and 74. (January 2010) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the benefits and harms of screening mammography in women aged 75 years and older. (January 2010) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against clinicians teaching women breast self-examination (BSE). (January 2010) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the benefits and harms of clinical breast examination (CBE) for women aged 40 years and older. (January 2010) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that current evidence is insufficient to assess benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film screen mammography as screening modalities for breast cancer. (January 2010) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against routine use of tamoxifen or raloxifene for the primary prevention of breast cancer in women at low or average risk for breast cancer. (2002) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. (2002) (Grade B recommendation) (Grade Definition) (Clinical Considerations: Clinicians should inform patients of the potential benefits and harms of chemoprevention)

The AAFP recommends that women whose family history is associated with an increased risk for deleterious mutations in breast cancer susceptibility gene BRCA1 or BRCA2 be referred for genetic counseling and evaluation for BRCA testing. (2005) (Grade: B recommendation) (Grade Definition) (Clinical Consideration)

The AAFP recommends against routine referral for genetic counseling or routine BRCA testing for women whose family history is not associated with increased risk for deleterious mutations in BRCA1 or BRCA2. (2005) (Grade: D recommendation) (Grade Definition) (Clinical Consideration)

Breastfeeding

The AAFP recommends interventions during pregnancy and after birth to promote and support breastfeeding. (2008) (Grade: B recommendation) (Grade Definition) (Clinical Consideration) (For Definition of Interventions)

Cardiovascular Disease

The AAFP recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. (2009) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (2009) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45 years. (2009) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the evidence is insufficient to assess the benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. (2009) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Carotid Artery Stenosis

The AAFP recommends against screening for asymptomatic carotid artery stenosis (CAS) in general adult populations. (2007) (Grade: D recommendation) (Grade Definition) (Clinical Consideration)

Cervical Cancer

The AAFP recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. (2012) (Grade: A recommendations) (Grade Definition) (Clinical Considerations)

The AAFP recommends against screening for cervical cancer in women younger than age 21 years. (2012) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors. (2012) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. (2012) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years. (2012) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Chlamydia

The AAFP recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk. (2007) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk. (2007) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against routinely providing screening for chlamydial infection for women aged 25 and older whether or not they are pregnant, if they are not at increased risk. (2007) (Grade: C recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection for men. (2007) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Chronic Obstructive Pulmonary Disease (COPD)

The AAFP recommends against screening asymptomatic adults for COPD using spirometry. (2008) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Colorectal Cancer

The AAFP recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risk and benefits of these screening methods vary. (2008) (Grade: A recommendation) (Grade Definition) (Go to Rationale and Clinical Consideration)

The AAFP recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient. (2008) (Grade: C recommendation) (Grade Definition) (Go to Rationale and Clinical Consideration)

The AAFP recommends against screening for colorectal cancer in adults older than age 85 years. (2008) (Grade: D recommendation) (Grade Definition) (Go to Rationale and Clinical Consideration)

The AAFP recommends against the routine use of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer in individuals at average risk for colorectal cancer. (2008) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal deoxyribonucleic acid (DNA) testing as screening modalities for colorectal cancer. (2008) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Congenital Hypothyroidism

The AAFP recommends screening for congenital hypothyroidism (CH) in newborns. (2008) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

Coronary Heart Disease

The AAFP recommends against screening with resting or exercise electrocardiography (ECG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events. (2012) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events. (2012) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors discussed in this statement to screen asymptomatic men and women with no history of CHD to prevent CHD events. (Select “Clinical Considerations” for suggestions for practice when evidence is insufficient). The nontraditional risk factors included in this recommendation are high-sensitivity C-reactive protein (hs-CRP), ankle-brachial index (ABI), leukocyte count, fasting blood glucose level, periodontal disease, carotid intima-media thickness (carotid IMT), coronary artery calcification (CAC) score on electron-beam computed tomography (EBCT), homocysteine level, and lipoprotein(a) level. (2010) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Dementia

The AAFP concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults. (2003) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Dental Caries

The AAFP strongly recommends ordering fluoride supplementation to prevent dental caries based on age and fluoride concentration of patient’s water supply for infants and children age 6 months through 16 years residing in areas with inadequate fluoride in the water supply (less than 0.6 ppm). (2004)

Depression

The AAFP recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. “Staff-assisted depression care supports” refers to clinical staff that assist the primary care clinician by providing some direct depression care and/or coordination, case management, or mental health treatment. (2010) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient. “Staff-assisted depression care supports” refers to clinical staff that assist the primary care clinician by providing some direct depression care and/or coordination, case management, or mental health treatment. (2010) (Grade: C recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends screening of adolescents (12 to 18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. (2009) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening of children (7 to 11 years of age). (2009) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Diabetes, Gestational

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes mellitus (GDM), either before or after 24 weeks’ gestation. (2008) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Diabetes, Type 2

The AAFP recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (2008) (Grade: B recommendation) (Grade Definition) (Clinical Consideration)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. (2008) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

Dysplasia (Developmental) of the Hip

The AAFP concludes that the evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes. (2006) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Family Violence and Intimate Partner Violence

The AAFP recognizes that all family physicians should be alert to physical and behavioral signs and symptoms associated with abuse or neglect. The AAFP concludes that the evidence is insufficient to recommend for or against screening of parents or guardians for the physical abuse or neglect of children, of adults or adolescents of either sex for intimate partner violence, or of older adults or their caregivers for elder abuse. (2004) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Falls Prevention in Older Adults

The AAFP recommends exercise or physical therapy and vitamin D supplementation in community-dwelling adults aged 65 years or older who are at increased risk for falls. See “Clinical Considerations” for information on risk assessment. (2012) (Grade: B recommendation.) (Grade Definition) (Clinical Consideration)

The AAFP does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older because the likelihood of benefit is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, co-morbid medical conditions, and patient values. (2012) (Grade: C recommendation) (Grade Definition) (Clinical Consideration)

Genital Herpes Simplex Virus (HSV) Infection

The AAFP recommends against routine serological screening for HSV in asymptomatic pregnant women at any time during pregnancy to prevent neonatal HSV infection. (2005) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against routine serological screening for HSV in asymptomatic adolescents and adults. (2005) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Glaucoma

The AAFP found insufficient evidence to recommend for or against screening adults for glaucoma. (2005) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Gonococcal Infection in Neonates

The AAFP strongly recommends prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum. (2005) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

Gonorrhea

The AAFP recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors); see “Clinical Consideration” for further discussion of risk factors. (2005) (Grade: A recommendation) (Grade Definition) (Clinical Consideration)

The AAFP concludes there is insufficient evidence to recommend for or against screening for gonorrhea infection in pregnant women who are not at increased risk for infection; see “Clinical Consideration” for further discussion of risk factors. (2005) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

The AAFP concludes there is insufficient evidence to recommend for or against routine screening for gonorrhea infection in men at increased risk for infection; see clinical consideration for further discussion of risk factors. (2005) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

The AAFP recommends against routine screening for gonorrhea infection in men and women who are at low risk for infection; see “Clinical Consideration” for further discussion of risk factors. (2005) (Grade: D recommendation) (Grade Definition) (Clinical Consideration)

Healthful Diet and Physical Activity for Cardiovascular Disease (CVD)

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: General adult population without a known diagnosis of hypertension, diabetes, hyperlipidemia, or cardiovascular disease. Issues to consider include other risk factors for cardiovascular disease, a patient’s readiness for change, social support and community resources that support behavioral change, and other health care and preventive service priorities. (2012) (Grade: C recommendation) (Grade Definition) (Clinical Consideration)

Healthy Diet

The AAFP recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care physicians or by other qualified professionals including dietitians and nutritionists. (1996) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

Hearing Difficulties

The AAFP recommends screening for hearing difficulties by questioning elderly adults about hearing impairment and counsel regarding the availability of treatment when appropriate. (1996) (Clinical Considerations)

Hearing Loss, Sensorineural (SNHL)

The AAFP recommends screening for hearing loss in all newborn infants. (2008) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

Hemochromatosis

The AAFP recommends against routine genetic screening for hereditary hemochromatosis in the asymptomatic general population. (2006) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Hepatitis B Virus (HBV) Infection

The AAFP recommends screening for HBV in pregnant women at their first prenatal visit. (2009) (Grade: A recommendation) (Grade Definition) (Clinical Consideration)

The AAFP recommends against routinely screening the general asymptomatic population for chronic HBV infection. (2004) (Clinical Consideration)

Hepatitis C Virus (HCV) Infection

The AAFP recommends against routine screening for HCV infection in asymptomatic adults who are not at increased risk (general population) for infection. (2004) (Grade: D recommendation) (Grade Definition) (Clinical Consideration)

The AAFP found insufficient evidence to recommend for or against routine screening for HCV infection in adults at high risk for infection. (2004) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

Human Immunodeficiency Virus (HIV) Infection

The AAFP strongly recommends that physicians screen for HIV all adolescents and adults at increased risk for HIV infection. (2005) (Grade: A recommendation) (Grade Definition) (Clinical Considerations for discussion of risk factors) Also see: HIV Policy Statement (August 2007)

The AAFP makes no recommendation for or against routinely screening for HIV in adolescents and adults who are not at increased risk for HIV infection. (2005) (Grade: C recommendation) (Grade Definition) (Clinical Considerations for discussion of risk factors) Also see: HIV Policy Statement (August 2007)

The AAFP recommends that clinicians screen all pregnant women for HIV. (2005) (Grade: A recommendation) (Grade Definition) (Clinical Considerations) Also see: HIV Policy Statement (August 2007)

Hormone Replacement Therapy

The AAFP recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women. (2012) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. (2012) This recommendation applies to postmenopausal women who are considering hormone therapy for the primary prevention of chronic medical conditions. This recommendation does not apply to women younger than age 50 years who have undergone surgical menopause. This recommendation does not consider the use of hormone therapy for the management of menopausal symptoms, such as hot flashes or vaginal dryness. (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Hyperbilirubinemia, Infants

The AAFP concludes that the evidence is insufficient to recommend screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy. (2009) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Hypertension

The AAFP recommends screening for high blood pressure in adults aged 18 and older. (2007) (Grade: A recommendation) (Grade Definition) (Clinical Consideration)

The AAFP concludes that the evidence is insufficient to recommend for or against routine screening for high blood pressure in children and adolescents to reduce the risk of cardiovascular disease.

Illicit Drug Use

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. (2008) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Immunization

The AAFP recommends immunizing all children 0 to 6 years of age using the AAFP recommendations unless contraindicated. (2010) (Grade: A recommendation) (Grade Definition) (Recommended Childhood Immunization Schedule)

The AAFP recommends immunizing children 0 to 6 years who are between doses for vaccinations with the AAFP recommendation unless contraindicated. (2010) (Grade: A recommendation) (Grade Definition) (Recommended Catch-up Immunization Schedule)

The AAFP recommends immunizing all adolescents 7 to 18 years of age using the AAFP recommendations unless contraindicated. (2010) (Grade: A recommendation) (Grade Definition) (Recommended Adolescent Immunization Schedule)

The AAFP recommends immunizing adolescents 7 to 18 years who are between doses for vaccinations with the AAFP recommendation unless contraindicated. (2010) (Grade: A recommendation) (Grade Definition) (Recommended Catch-up Immunization Schedule)

The AAFP recommends immunizing all adults using the AAFP recommendations unless contraindicated. (2010) (Grade: A recommendation) (Grade Definition) (Recommended Adult Immunization Schedule)

Insulin Dependent Diabetes Mellitus

The AAFP recommends against the use of immune marker screening for insulin dependent diabetes mellitus in asymptomatic persons.

Iron Deficiency Anemia

The AAFP recommends routine screening for iron deficiency anemia in asymptomatic pregnant women. (2006) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the evidence is insufficient to recommend for or against routine screening for iron deficiency anemia in asymptomatic children aged 6 to 12 months. (2006) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Lead Poisoning

The AAFP concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at increased risk. (2006) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against routine screening for elevated blood levels in asymptomatic children aged 1 to 5 years who are at average risk. (2006) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against routine screening for elevated blood levels in asymptomatic pregnant women. (2006) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Lipid Disorders

The AAFP recommends screening men aged 35 and older for lipid disorders. (2008) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. (2008) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. (2008) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. (2008) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

The AAFP makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease. (2008) (Grade: C recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the evidence is insufficient to recommend for or against routine screening for lipid disorders in infants, children, adolescents, or young adults (up to age 20). (2007) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Low Back Pain

The AAFP concludes that the evidence is insufficient to recommend for or against routine use of interventions to prevent low back pain in adults in primary care settings. (2004) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

Lung Cancer

The AAFP concludes that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests. (2004) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Motor Vehicles

The AAFP recognizes the use of motor vehicle occupant restraints is desirable to prevent motor vehicle occupant injuries. The effectiveness of physician’s advice and counseling in this is area is uncertain. (2007) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recognizes that avoiding driving while alcohol impaired is desirable. The effectiveness of routine counseling of patients to reduce driving while under the influence of alcohol or riding with drivers who are alcohol-impaired is uncertain. (2007) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Neural Tube Defects

The AAFP recommends that all women planning or capable of pregnancy take a daily supplement containing 0.43 to 0.8 mg (400 to 800 μg) of folic acid. (2009) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

Obesity

The AAFP recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. (2012) Intensive, multicomponent behavioral interventions include behavioral management activities (12 to 26 sessions in the first year) such as setting weight loss goals, improving diet/nutrition and increasing physical activity, addressing barriers to change, self-monitoring, and strategizing how to maintain lifestyle changes. See “Clinical Considerations” section for more information. (Grade: B recommendation) (Grade Definition) (Clinical Consideration)

The AAFP recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. (February 2010) (Grade: B recommendation) (Grade Definition) (Clinical Consideration [The definitions for specific interventions (targeted to diet and physical activity) and intensity (>25 hours with child and/or family over 6 months) are noted in the clinical considerations.])

Oral Cancer

The AAFP concludes that the evidence is insufficient to recommend for or against routinely screening adults for oral cancer. (2004) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

Osteoporosis

The AAFP recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year old white woman who has no additional risk factors. A 65-year-old white woman with no other risk factors has a 9.3% 10-year risk for any osteoporotic fracture. (2011) (Grade: B recommendation) (Grade Definition) The FRAX (Fracture Risk Assessment) tool, available at www.shef.ac.uk/FRAX/, can be used to estimate 10-year risks for fractures for all racial and ethnic groups in the United States. (2011) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. (2011) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Ovarian Cancer

The AAFP recommends against screening for ovarian cancer. (2012) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing. (2005) (Grade: B recommendation) (Grade Definition) (Clinical Consideration)

The AAFP recommends against routine referral for genetic counseling or routine BRCA testing for women whose family history is not associated with increased risk for deleterious mutations in BRCA1 or BRCA2. (2005) (Grade: D recommendation) (Grade Definition) (Clinical Consideration)

Pancreatic Cancer

The AAFP recommends against routine screening for pancreatic cancer in asymptomatic adults using abdominal palpation, ultrasonography, or serologic markers. (2004) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Peripheral Arterial Disease

The AAFP recommends against routine screening for peripheral arterial disease (PAD). (2005) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Phenylketonuria

The AAFP recommends ordering screening test for phenylketonuria in neonates. (2008) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

Prostate Cancer

The AAFP recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. (2012) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Rh (D) Incompatibility

The AAFP strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. (2004) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 to 28 weeks’ gestation. (2004) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

Scoliosis, Idiopathic

The AAFP recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis. (2004) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Second-Hand Smoke

The AAFP strongly recommends to counsel smoking parents with children in the house regarding the harmful effects of smoking and children’s health.

Sexually Transmitted Infections (STIs)

The AAFP recommends high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs. (2008) (Grade: B recommendation) (Grade Definition) (Clinical Considerations for risk assessment)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of behavioral counseling to prevent STIs in non-sexually active adolescents and in adults not at increased risk for STIs. (2008) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Sickle Cell Disease

The AAFP recommends screening for sickle cell disease in all newborns. (2007) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

Skin Cancer

The AAFP recommends counseling children, adolescents, and young adults ages 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk of skin cancer. (2012) (Grade: B recommendation) (Grade Definition) (Clinical Consideration)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults older than age 24 years about minimizing risks to prevent skin cancer. (2012) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population. (2009) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Speech and Language Delay

The AAFP concludes that the evidence is insufficient to recommend for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age. (2006) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Suicide

The AAFP concludes that the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population. (2004) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Syphilis

The AAFP strongly recommends that clinicians screen persons at increased risk for syphilis infection. (2004) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against routine screening of asymptomatic persons who are not at increased risk for syphilis infection. (2004) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends that clinicians screen all pregnant women for syphilis infection. (2009) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

Testicular Cancer

The AAFP recommends against screening for testicular cancer in asymptomatic adolescent or adult males. (2011) (Grade: D recommendation) (Grade Definition) (Clinical Consideration)

Thyroid Cancer

The AAFP recommends against the use of ultrasound screening for thyroid cancer in asymptomatic persons. (1996) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Thyroid Disease

The AAFP concludes that the evidence is insufficient to recommend for or against routine screening for thyroid disease in adults. (2004) (Grade: I recommendation) (Grade Definition) (Clinical Consideration)

Tobacco Use

The AAFP recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (2009) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP strongly recommends that clinicians screen all pregnant women for tobacco use and provide 5 to 15 minutes of smoking cessation counseling using messages and self-help materials tailored for pregnant smokers. (2003) (Grade: A recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recognizes avoidance of tobacco products by children and adolescents is desirable. The effectiveness of physician advice and counseling in this area is uncertain. (2003) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Visual Difficulties

The AAFP concludes that the current evidence is insufficient to assess the balance of benefit and harms of screening for visual acuity for the improvement of outcomes in older adults. (2009) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Visual Impairment

The AAFP recommends vision screening for all children at least once between the ages of 3 and 5 years to detect the presence of amblyopia or its risk factors. (2011) (Grade: B recommendation) (Grade Definition) (Clinical Considerations)

The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children <3 years of age. (2011) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

Vitamin Supplementation, for Cancer and Heart Disease

The AAFP concludes that the evidence is insufficient to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease. (2003) (Grade: I recommendation) (Grade Definition) (Clinical Considerations)

The AAFP recommends against the use of beta-carotene supplements, either alone or in combination, for the prevention of cancer or cardiovascular disease. (2003) (Grade: D recommendation) (Grade Definition) (Clinical Considerations)

Definitions:

Grades of Recommendation

The AAFP grading system for the recommendations that occurred during or after May 2007 includes:

A Recommendation: The AAFP recommends the service. There is high certainty that the net benefit is substantial.

B Recommendation: The AAFP recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

C Recommendation: The AAFP recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.

D Recommendation: The AAFP recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

I Recommendation: The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

I-HB Healthy Behavior is identified as desirable but the effectiveness of physician’s advice and counseling is uncertain.

The AAFP grading system for those recommendations before May 2007 includes:

SR Strongly Recommend: Good quality evidence exists which demonstrates substantial net benefit over harm; the intervention is perceived to be cost effective and acceptable to nearly all patients.

R Recommend: Although evidence exists which demonstrates net benefit, either the benefit is only moderate in magnitude or the evidence supporting a substantial benefit is only fair. The intervention is perceived to be cost effective and acceptable to most patients.

NR No Recommendation Either For or Against: Either good or fair evidence exists of at least a small net benefit. Cost-effectiveness may not be known or patients may be divided about acceptability of the intervention.

RA Recommend Against: Good or fair evidence which demonstrates no net benefit over harm.

I Insufficient Evidence to Recommend Either For or Against: No evidence of even fair quality exists or the existing evidence is conflicting.

I-HB Healthy Behavior is identified as desirable but the effectiveness of physician’s advice and counseling is uncertain.

The type of supporting evidence is not specifically stated for each recommendation.

The recommendations are based on review of scientific knowledge presented by the U.S. Preventive Services Task Force (USPSTF).

Health maintenance and disease prevention in healthy and at-risk population.

  • Physicians are encouraged to review not only the needs of individual patients they see, but also of the populations in the communities they serve to determine which specific population recommendations need to be implemented systematically in their practices. The recommendations contained in this document are for screening, chemoprophylaxis and counseling only. They do not necessarily apply to patients who have signs and/or symptoms relating to a particular condition.
  • These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These recommendations are only one element in the complex process of improving the health of America. To be effective, the recommendations must be implemented.
  • An implementation strategy was not provided.
American Academy of Family Physicians (AAFP). Summary of recommendations for clinical preventive services. Leawood (KS): American Academy of Family Physicians (AAFP); 2012 Oct. 19 p.

The starting point for the recommendations is the rigorous analysis of scientific knowledge available as presented by the U.S. Preventive Services Task Force (USPSTF).

American Academy of Family Physicians (AAFP)

Commission on Health of the Public and Science (CHPS)

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Family Physicians (AAFP). Summary of recommendations for clinical preventive services. Leawood (KS): American Academy of Family Physicians (AAFP); 2012 May. 18 p.

Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Family Physicians (AAFP) Web site.

Print copies: Available from the American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211.

This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. The information was updated by ECRI on October 31, 2001, February 14, 2002, October 7, 2002, January 13, 2004, December 7, 2004, and August 5, 2005. This summary was updated by ECRI on October 5, 2005 following the U.S. Food and Drug Administration (FDA) advisory on Menactra (Meningococcal Conjugate Vaccine A, C, Y, and W135). This summary was updated by ECRI on November 15, 2005. This summary was updated by ECRI on October 25, 2006 following the updated FDA advisory on Menactra (Meningococcal Conjugate Vaccine). This NGC summary was updated by ECRI Institute on November 13, 2006, October 30, 2007, and on December 11, 2007. The updated information was verified by the guideline developer on November 16, 2007. This NGC summary was updated by ECRI Institute on June 24, 2009, July 30, 2010, June 24, 2011, December 23, 2011, May 31, 2012, and December 12, 2012.

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