Appendix A Task Force Ratings The tables of ratings on the following pages were developed for the U.S. Preventive Services Task Force using the methodology adapted from the Canadian Task Force on the Periodic Health Examinationa and described in Chapter ii. For this edition of the Guide, the Task Force developed ratings for all of the topics examined. The Task Force graded the strength of recommendations for or against preventive interventions as follows. Strength of Recommendations A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Determination of the quality of evidence (i.e., "good," "fair," "insufficient") in the strength of recommendations was based on a systematic consideration of three criteria: the burden of suffering from the target condition, the characteristics of the intervention, and the effectiveness of the intervention as demonstrated in published clinical research. Effectiveness of the intervention received special emphasis. In reviewing clinical studies, the Task Force used strict criteria for selecting admissible evidence and placed emphasis on the quality of study designs. In grading the quality of evidence, the Task Force gave greater weight to those study designs that, for methodologic reasons, are less subject to bias and inferential error. The following rating system was used. Quality of Evidence I: Evidence obtained from at least one properly randomized controlled trial. II-1: Evidence obtained from well-designed controlled trials without randomization. II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence. III: Opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees. Well-designed and well-conducted meta-analyses were also considered, and were graded according to the quality of the studies on which the analyses were based (e.g., Grade I if the meta-analysis pooled properly randomized controlled trials). An exact correlation does not exist between the strength of the recommendation and the level of evidence, i.e., Level I evidence did not necessarily lead to an A grade, nor did an A grade require Level I evidence. For example, there may have been evidence of good quality that did not prove that an intervention is effective (e.g., mammography in women under age 50, which received a C recommendation). On the other hand, an A recommendation was given to screening for cervical cancer with Papanicolaou testing, based on burden of suffering and Level II evidence supporting the effectiveness of the intervention. For many preventive services, there is insufficient evidence to determine whether or not routine intervention will improve clinical outcomes (C recommendation). A variety of different circumstances can result in a OCO recommendation: available studies are not adequate to determine effectiveness (e.g., insufficient statistical power, unrepresentative populations, lack of clinically important endpoints, or other important design flaws); high-quality studies have produced conflicting results; evidence of significant benefits is offset by evidence of important harms from intervention; or studies of effectiveness have not been conducted. As a result, lack of evidence of effectiveness does not constitute evidence of ineffectiveness. Chapter ii provides further information about the methodology used to develop the body of this report. Table 1. Screening for Asymptomatic Coronary Artery Disease Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine resting, II-2 C ambulatory, or exercise electrocardiography in middle-aged or older persons Routine resting electro- III D cardiography in healthy children, adolescents, or young adults, including those undergoing pre-participation sports physicals Table 2. Screening for High Blood Cholesterol and Other Lipid Abnormalities Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine measurement of total serum or blood cholesterol Men aged 35-65 yr I, II-2 B Women aged 45-65 yr II-2 B Persons aged > 65 yr II-2 C Children, adolescents, II-2 C young adults Routine measurement of HDL-C II-2, III C Routine measurement of II-2 C triglycerides Table 3. Screening for Hypertension Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Periodic blood pressure I A measurement in persons aged 21 yrs or older Measurement of blood II-2, II-3, III B pressure in children and adolescents during office visits Table 4. Screening for Asymptomatic Carotid Artery Stenosis Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine carotid I, II-2 C ultrasound or auscultation for carotid bruits in older persons Table 5. Screening for Peripheral Arterial Disease Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine history-taking III D for classic claudication, palpation of peripheral pulses, ultrasound, or other noninvasive tests in older persons Table 6. Screening for Abdominal Aortic Aneurysm Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine abdominal II-2 C palpation Routine abdominal II-2 C ultrasound Table 7. Screening for Breast Cancer Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine mammogram every 1-2 yr with or without annual clinical breast exam Women aged 40-49 yr I C 50-69 yr I, II-2 A 70-74 yr I, II-3 C 75 yr and older III C Annual clinical breast exam without periodic mammograms Women aged 40-49 yr III C 50-59 yr I C 60 yr and older III C Routine breast self-exam I, II-2, III C Table 8. Screening for Colorectal Cancer Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Annual fecal occult I, II-1, II-2 B blood testing of persons aged 50 yr and older Routine sigmoidoscopy II-2, II-3 B in persons aged 50 yr and older Routine digital rectal exam III C Routine barium enema III C Routine colonoscopy III C Table 9. Screening for Cervical Cancer Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Regular Pap testing in II-2, II-3 A women who are or have been sexually active and who have a cervix Discontinuation of III C regular Pap testing in women aged >65 yr Routine cervicography or III C colposcopy Routine testing for HPV III C infection Table 10. Screening for Prostate Cancer Intervention Level of Evidence Strength of Recommendation ------------------------------------------------------------------------- Routine digital rectal II-2 D exam Routine prostate-specific I, II-2, III D antigen or other serum tumor markers Routine transrectal ultrasound II-2, III D Table 11. Screening for Lung Cancer Intervention Level of Evidence Strength of Recommendation ------------------------------------------------------------------------- Routine chest x-ray I, II-1, II-2 D or sputum cytology Table 12. Screening for Skin Cancer-Including Counseling to Prevent Skin Cancer Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Screening Total body skin exam by II-3, III C primary care clinicians Periodic skin self-exam II-3, III C Primary Prevention Sun avoidance or use of II-2 B protective clothing by high-risk* persons Routine use of sunscreens I, II-2 C Clinician counseling to III C increase the use of sun protection measures Table 13. Screening for Testicular Cancer Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine self-exam or III C physician exam of the testes in men Table 14. Screening for Ovarian Cancer Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine pelvic exam, ultrasound, or serum tumor markers General female population II-3, III D High-risk* women III C Table 15. Screening for Pancreatic Cancer Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine abdominal III D palpation, ultrasound, or serum tumor markers Table 16. Screening for Oral Cancer Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine oral exam III C by primary care clinicians Table 17. Screening for Bladder Cancer Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine urine dipstick II-2, III D or microscopy Routine urine cytology III D Table 18. Screening for Thyroid Cancer Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine neck palpation or ultrasound General population II-2, III D High-risk* adults III C or children Table 19. Screening for Diabetes Mellitus Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Non-insulin-dependent: Routine measurement of II-2 C plasma glucose, glyco- sylated hemoglobin, or urine glucose Gestational: Routine oral 1-hr I, II-2 C glucose challenge test, glycosolated hemoglobin, fasting or random plasma glucose, or urine glucose Insulin-dependent: Routine measurement of III D serum auto-antibodies in the general population Table 20. Screening for Thyroid Disease Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine thyroid function tests General population III D High-risk* persons I, II-3 C Table 21. Screening for Obesity Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Periodic height and I, II-2, II-3 B weight measurements Routine determination II-2 C of the waist/hip ratio Table 22. Screening for Iron Deficiency Anemia-Including Iron Prophylaxis Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Screening Routine hemoglobin/ hematocrit Pregnant women at II-1, II-2 B first prenatal visit High-risk* infants I B High-risk* children I C General population I, II-1, II-2 C Repeat hemoglobin/ III C hematocrit in pregnant women or high-risk* infants not anemic at initial testing Primary Prevention Breastfeeding and use of iron- I, II-1, II-2, II-3 B enriched formula or food for all infants and toddlers Routine use of iron supplements Healthy pregnant women I, II-1, II-2 C Healthy infants I, III C Table 23. Screening for Elevated Lead Levels in Childhood and Pregnancy Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Screening Routine blood lead measurement High-risk* children II-1, II-2, II-3 B Pregnant women III C Primary Prevention Routinely counseling II-2, III C families to control lead dust by repeated household cleaning, or to optimize caloric, iron, and calcium intake specifically to reduce lead absorption Table 24. Screening for Hepatitis B Virus Infection Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine measurement of HBsAg Pregnant women I, II-1, II-2, II-3 A High-risk* persons III C (to assess eligibility for vaccination) General population III D Table 25. Screening for Tuberculous Infection-Including BCG Immunization Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Tuberculin skin testing I A of high-risk* persons BCG vaccination of I, II-2 B selected high-risk* infants and children Table 26. Screening for Syphilis Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine serologic testing High-risk* persons II-3 A Pregnant women II-3 A Table 27. Screening for Gonorrhea-Including Ocular Prophylaxis in Newborns Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Screening Routine gonorrhea culture or nonculture screening test High-risk* women II-2, III B High-risk* pregnant women II-2 B Other pregnant women III C High-risk* men II-3, III C General population III D Primary Prevention of Gonococcal Ophthalmia Neonatorum Routine ophthalmic anti- II-3, III A biotic in newborns Table 28. Screening for Human Immunodeficiency Virus Infection Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Enzyme immunoassay, with confirmatory test for positive results High-risk* adolescents I, II-2 A and adults High-risk* pregnant women I, II-2 A High-risk* infants II-2 B Low-risk pregnant women, III C adolescents,and adults Table 29. Screening for Chlamydial InfectionÑIncluding Ocular Prophylaxis in Newborns Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Screening Routine culture or non- culture screening test Sexually active female I, II-2, III B adolescents and other high-risk* women High-risk* pregnant women II-2 B Other pregnant women III C High-risk* men II-3, III C General population III D Primary Prevention of Chlamydial Ophthalmia Neonatorum Routine ophthalmic I, II-2, III C antibiotic in newborns Table 30. Screening for Genital Herpes Simplex Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Screening Routine viral culture, serology, or other tests General population II-3, III D Pregnant women II-2, II-3, III D Examination of pregnant II-2, III C women in labor for signs of active genital HSV lesions Primary Prevention of Neonatal Herpes Infection Routine use of systemic III C acyclovir in pregnant women with recurrent herpes Counseling uninfected women III C with infected partners to use condoms or abstain from intercourse during pregnancy Table 31. Screening for Asymptomatic Bacteriuria Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine urine culture in I A pregnant women at 12-16 weeks' gestation Routine urine dipstick for leukocyte esterase/ nitrites Pregnant women II-2 D Diabetic women III C Noninstitutionalized I, II-1, II-2 C elderly women Institutionalized elders I E School-aged girls I E Other persons I, II-2, III D Routine urine microscopy II-2 D Table 32. Screening for Rubella-Including Immunization of Adolescents and Adults Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine rubella serology or vaccination history Women of childbearing age II-2, II-3, III B (including pregnant women) Young men in high-risk* II-3, III C settings Other men and postmenopausal III D women Routine rubella vaccination without screening Children I, II-1, II-2, II-3 A Nonpregnant women of II-2, III B childbearing age Young men in high-risk* II-2, III C settings Other men and postmenopausal III D women Table 33. Screening for Visual Impairment Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine testing for II-1, II-2 B amblyopia and strabismus in preschool children Routine Snellen acuity II-3 B testing in elderly persons Routine ophthalmoscopy by III C primary care clinicians in elderly persons Routine vision screening in III C other children, adolescents, and adults Table 34. Screening for Glaucoma Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine tonometry I, II-2, III C Routine ophthalmoscopy III C by primary care clinicians Table 35. Screening for Hearing Impairment Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Periodically questioning I, III B older adults about their hearing Routine audiometric testing I, III C in older adults Routine hearing testing in III C adolescents and working-age adults<1> Routine evoked otoacoustic II-2, III C emission testing or auditory brainstem response in newborns Routine hearing testing in II-2 D children aged >3 yr <1>Screening of workers for noise-induced hearing loss should be performed in the context of existing worksite programs and occupational medicine guidelines. Table 36. Screening Ultrasonography in Pregnancy Intervention Level of Evidence Strength of Recommendation -------------------------------------------------------------------------- Routine midtrimester I C ultrasound in pregnant women Routine third-trimester I D ultrasound in pregnant women Table 37. Screening for Preeclampsia Intervention Level of Evidence Strength of Recommendation ------------------------------------------------------------------------- Periodic blood pressure II-3, III B measurement during pregnancy, as part of routineprenatal care Table 38. Screening for D (Rh) Incompatibility Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine D (Rh) blood I, II-1, II-3 A typing and antibody testing of pregnant women at the first visit Repeat antibody testing of II-1 B all unsensitized D-negative pregnant women at 24-28 weeks' gestation Routine administration of D immunoglobulin to unsensitized D-negative women Postpartum I, II-1 A At 24-28 weeks' gestation II-1 B After amniocentesis or II-1, II-3 B induced abortion After CVS, other high-risk* I, III C obstetric procedures or complications Table 39. Intrapartum Electronic Fetal Monitoring Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine intrapartum electronic fetal monitoring Low-risk pregnancies I D High-risk* pregnancies I C Table 40. Home Uterine Activity Monitoring Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Home uterine activity monitoring Normal risk pregnancies III D High-risk* pregnancies I, II-2 C Table 41. Screening for Down Syndrome Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Offering amniocentesis or II-2 B CVS to high-risk*pregnant women Offering maternal serum II-2 B multiple-marker testing to all pregnant women Offering maternal serum II-2 C individual marker testing to pregnant women Offering midtrimester II-2, III C ultrasound to pregnant women Table 42. Screening for Neural Tube Defects-Including Folate Prophylaxis Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Screening Offering maternal serum II-2 B a-fetoprotein measurement to all pregnant women Offering midtrimester I, II-2, III C ultrasound to all pregnant women Primary Prevention Periconceptional folic acid I A 4.0 mg daily for women with previous affected pregnancy Daily multivitamin or multi- I, II-2 A vitamin/multimineral containing 0.4D0.8 mg folic acid for women planning pregnancy Daily multivitamin containing II-2 B 0.4 mg folic acid for women capable of pregnancy Dietary folate intake of II-2 C 0.4 mg/day for women capable of pregnancy Table 43. Screening for Hemoglobinopathies Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Testing for hemoglobin- I, II-2 A opathies in newborns Offering testing for hemoglobinopathies with counseling Pregnant women at first II-2, II-3, III B prenatal visit High-risk* adolescents and II-1, III C young adults Table 44. Screening for Phenylketonuria Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine measurement of II-3 A phenylalanine level on dried-blood spot specimens in newborns Routine measurement of blood II-2, III C phenylalanine level in pregnant women Table 45. Screening for Congenital Hypothyroidism Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine measurement of T4 II-3 A and/or TSH on dried-blood spot specimens in newborns Table 46. Screening for Postmenopausal Osteoporosis Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine bone densitometry II-2, III C in postmenopausal women Table 47. Screening for Adolescent Idiopathic Scoliosis Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine forward-bending II-3, III C test, visual inspection of the back, inclinometer, or other tests in adolescents Table 48. Screening for Dementia Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine use of standardized III C screening tests in elderly persons Table 49. Screening for Depression Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine use of standardized I, II-1 C screening tests in primary care patients Table 50. Screening for Suicide Risk Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Screening Routine use by primary I, II-2, II-3 C care clinicians of direct questions or standardized screening tests in the general population Primary Prevention Training primary care II-3 B clinicians to recognize and treat affective disorders Table 51. Screening for Family Violence Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine standardized III C interview or physical exam to detect child abuse Routine standardized III C interview to detect elder abuse Routine standardized II-3, III C questionnaire to detect domestic violence Table 52. Screening for Problem Drinking Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine interview or I, II-2 B standardized questionnaire to detect problem drinking Adolescents and adults I, II-2 B Pregnant women II-2 B Table 53. Screening for Drug Abuse Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Routine screening with III C standardized questionnaires or biologic assays Table 54. Counseling to Prevent Tobacco Use Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Avoidance or cessation II-2 A of tobacco use to reduce the risk of cancer, cardiovascular and respiratory diseases, adverse pregnancy and neonatal outcomes, and effects of passive smoking Effectiveness of Counseling and Other Clinical Interventions Clinician counseling of I A all patients, including pregnant women, who use tobacco to reduce or stop use Nicotine patches or gum as I A an adjunct to counseling Clonidine as an adjunct I C to counseling Clinician counseling of III<1> C school-aged children and adolescents to avoid tobacco use <1>Controlled trials have demonstrated the ability of school-based intervention programs to delay the initiation of tobacco use in children and adolescents. Table 55. Counseling to Promote Physical Activity Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Regular physical activity II-2 A to prevent coronary heart disease, hypertension, obesity, and other diseases Effectiveness of Counseling Counseling patients to I, II-2 C incorporate regular physical activity into their daily routines Table 56. Counseling to Promote a Healthy Diet Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction in the General Population Limiting intake of dietary I, II-2, II-3 A fat (especially saturated fat) Limiting intake of dietary II-2 B cholesterol Emphasizing fruits, II-2, II-3 B vegetables and grain products containing fiber Maintaining caloric balance II-2 B through diet and exercise Maintaining adequate intake I, II-1, II-2, II-3 B of dietary calcium in women Reducing intake of dietary II-3 C sodium Increasing intake of II-2, II-3, III C dietary iron Increasing intake of II-2, II-3 C beta-carotene and other antioxidants Breastfeeding infants I, II-2 A Effectiveness of Counseling Counseling to change dietary habits Specially trained educators I<1> B Primary care clinicians III C <1>These trials generally involved specially trained educators such as dieticians delivering intensive interventions (e.g., multiple sessions, tailored materials) to selected patients with known risk factors. Table 57. Counseling to Prevent Motor Vehicle Injuries Intervention Level of Evidence Strength of Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Child safety seats, II-2, II-3 A lap/shoulder belts, and motorcycle helmets Avoidance of driving while II-2, II-3 A impaired by alcohol or other drugs Driver- and passenger-side II-2 A air bags Alteration of pedestrian II-1, II-2, II-3 C behavior Effectiveness of Counseling Counseling parents to have I, II-1, II-2 B their children use car safety seats or seat belts as appropriate for age Counseling adolescent II-1, II-3 B and adult patients to use lap/shoulder belts Counseling patients to use III C motorcycle helmets Counseling problem drinkers I B to reduce their alcohol consumption (see Ch. 52) Counseling patients to avoid III C driving while impaired by alcohol or other drugs Counseling patients and III C parents of child patients on safe pedestrian behavior Table 58. Counseling to Prevent Household and Recreational Injuries Level of Strength of Intervention Evidence Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Fires and Burns Properly installed/tested smoke detectors II-2 B Smoking cessation (see Ch. 54) II-2 A Flame-retardant sleepwear for children II-3 A Hot water heaters set to <120-130deg. F II-3 A Drowning Four-foot, four-sided isolation fences with II-2 B self-latching gates Cardiopulmonary resuscitation (CPR) II-2, III B training Poisonings Child-proof containers for medications II-3 A Limitation of number of tablets packaged II-3 A Poison-warning stickers designed for II-1 D children (e.g., "Mr. Yuk" stickers) Bicycling and ATV Injuries Approved bicycle and ATV helmets II-2, II-3 A Avoidance of bicycling near traffic II-2, III B ATVs with smaller engines and 4 wheels II-2 B Training in safe bicycling behavior I, III C Alcohol-Related Injuries Avoidance of swimming, boating, bicycling, II-2 B hunting, or smoking while intoxicated Falls in Children Window guards in high-risk* II-3 A buildings Falls in Elderly Persons Exercise, especially balance training I, II-1, II-2 B Home-based multifactorial fall prevention I, II-2 B interventions in high-risk* elders External hip protectors in institutionalized II-1 C elderly persons Other Injury Prevention Measures III C (see Ch. 58 for details) Effectiveness of Counseling Counseling parents of young children on I, II-1, B measures to reduce injury risk II-2, II-3 Counseling adolescents and adults on I, III C measures to reduce injury risk Counseling problem drinkers to reduce I B alcohol consumption (see Ch. 52) Counseling elderly patients to address risk I C factors for falls *See relevant chapter for definition of high risk. Table 59. Counseling to Prevent Youth Violence Intervention Level of Strength of Evidence Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Removal or safe storage of II-2, II-3, III B firearms in the home Acquisition of interpersonal - II-2, III C problem solving skills Reduction of heavy or problem II-2, II-3, III B drinking Reduction of illicit drug use or II-2, III C drug trafficking Effectiveness of Counseling Counseling problem drinkers to reduce I B alcohol consumption (see Ch. 52) Counseling on measures to reduce III C violence risk Table 60. Counseling to Prevent Low Back Pain Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Exercise to strengthen back or I, II-1, II-2 C abdominal muscles or to improve overall fitness Corsets/back belts I, II-2 C Modification of risk factors (smoking, II-2, III C obesity, psychological factors) Effectiveness of Counseling Back pain prevention education Workplace I, II-1, II-2 C Pregnant women II-1 C Primary care patients III C Table 61. Counseling to Prevent Dental and Periodontal Disease Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Regular visits to dental care provider (for I B services such as professionally applied topical fluorides, sealants) Toothbrushing with fluoride-containing I, III B toothpaste Dental flossing II-1 B Avoidance of putting infants and children II-2, III B to bed with a bottle Reduced and less frequent intake of II-2 C sugary foods Fluoride supplementation of persons II-1 A aged <16 yr, in areas with inadequate water fluoridation Effectiveness of Counseling Counseling patients (parents) to follow II-2, II-3 C measures to reduce their (their children's) risk of oral disease Table 62. Counseling to Prevent HIV Infection and Other Sexually Transmitted Diseases Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Sexual abstinence or maintenance of II-2 A mutually faithful monogamous sexual relationship Regular use of condoms II-2, II-3 A Regular use of female barrier I<1>, II-2 B contraceptives and spermicides Avoidance of contaminated injection II-2 A equipment Effectiveness of Counseling Counseling by primary care clinicians to I, II-2 C reduce high-risk* sexual behavior or injection drug use <1>Benefit demonstrated for gonorrhea and chlamydia, but effects on HIV infection uncertain. *See relevant chapter for definition of high risk. Table 63. Counseling to Prevent Unintended Pregnancy Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Sexual abstinence or regular II-2 A use of contraceptives Effectiveness of Counseling Clinician counseling to improve II-3 B the effective use of contraceptives Clinician counseling to promote III C sexual abstinence among adolescents Table 64. Counseling to Prevent Gynecologic Cancers Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Efficacy of Risk Reduction Oral contraceptives to prevent II-2 B ovarian and endometrial cancer Avoidance of high-risk* sexual II-2 A activity, use of barrier contra- ceptives and spermicides to prevent cervical cancer Tubal sterilization to prevent II-2 B ovarian cancer Effectiveness of Counseling Counseling about measures to III C reduce risk of gynecologic cancers Table 65. Childhood Immunizations<1> Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Routine Childhood Immunizations Diphtheria \\ Pertussis \\ Tetanus \\ Poliomyelitis \\ I, II-3 A Measles // Rubella // Mumps // H. influenzae type b conjugate I, II-1, II-2, II-3 A Hepatitis B I, II-2, II-3 A Varicella I, II-3 A Immunizations for High-Risk* Children Hepatitis A (age 32 yr) I, II-3 A Influenza (age 36 mo) (see Ch. 66) II-2 B Pneumococcus (age 32 yr) (see Ch. 66) Immunocompetent I, II-2 B Immunocompromised I, II-2 C Healthy persons living in epidemic I A conditions Chemoprophylaxis Against Influenza A Amantadine/rimantadine - I B for high risk* children (see Ch. 66) <1>See Ch. 25 for recommendations on the use of BCG vaccine against tuberculosis. Table 66. Adult Immunizations-Including Chemoprophylaxis Against Influenza A Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Routine Adult Immunizations Influenza (age 365 yr) I, II-2 B Pneumococcus (age 365 yr) II-2 B Tetanus-diphtheria I, II-3 A Hepatitis B (young adults) I, II-3 A Immunizations for High-Risk* Adults Influenza II-2 B Pneumococcus Immunocompetent I, II-2 B Immunocompromised I, II-2 C Healthy young adults living I A in epidemic conditions Hepatitis B I, II-3 A Hepatitis A I B Measles-mumps-rubella I A Measles-mumps-rubella (second dose) II-2, II-3 B Varicella (see Ch. 65) I, II-3 B Chemoprophylaxis Against Influenza A Amantadine/rimantadine for high-risk* adults I B Table 67. Postexposure Prophylaxis for Selected Infectious Diseases Level of Strength of Disease Intervention Evidence Recommendation --------------------------------------------------------------------------- H. influenzae type b Rifampin I, II-3 A Hepatitis A Immune globulin II-1 A Hepatitis B Immune globulin/vaccine I A N. meningitidis Rifampin I, II-1 A Vaccine<1> I, II-1, II-3 A Ceftriaxone I C<2> Rabies Immune globulin/ I, II-3 A postexposure vaccine Preexposure vaccine II-1 A in high-risk* persons Tetanus Vaccine/immune II-1,II-2,II-3 A globulin <1>Persons 33 mo in serogroup A outbreaks; persons 32 yr in serogroup C, Y, and W135 outbreaks. <2>The efficacy of ceftriaxone in eliminating pharyngeal carriage of meningococcus has been confirmed only for serogroup A strains. Table 68. Postmenopausal Hormone Prophylaxis Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Routinely counseling peri- and I, II-2 B postmenopausal women about the risks and benefits1 of hormone prophylaxis <1>Hormone prophylaxis reduces the risk of osteoporosis and coronary heart disease, but may increase the risk of endometrial and breast cancer. Table 69. Aspirin Prophylaxis for the Primary Prevention of Myocardial Infarction Strength of Intervention Level of Evidence Recommendation --------------------------------------------------------------------------- Routine aspirin prophylaxis Middle-aged or older men I C Middle-aged women II-2 C Table 70. Aspirin Prophylaxis in Pregnancy Level of Strength of Intervention Evidence Recommendation --------------------------------------------------------------------------- Routine aspirin prophylaxis to prevent preeclampsia Pregnant women I C High-risk* pregnant women I C Routine aspirin prophylaxis to prevent intrauterine growth retardation in High-risk* pregnant women I, II-1 C