Geriatric Immunization & ScreeningMedicine Across the Lifespan Week 1

Wednesday, December 14, 2011

Shelley Bhattacharya, DO, MPH S

Immunization Special Populations

o Hepatitis A o Hepatitis B o MMR booster o Meningococcal Special Populations Bar Graph fo Begins in Adolescence >65 yrs old Adult Immunization is prepared ANUALLY Common Immunizations in Clinic o Td booster every 10 years

o o
o

substitute Tdap if its 1st tetanus shot any age If over 65 & w/ contact of infant under 12 mo of age, need Tdap (ADD PERTUSIS)-At least 2 wks before in contact with infant Varicella- 2 doses (0, 4-8 weeks later) at any age if lack evidence of immunity Zoster- one dose only at age 60 regardless of history of herpes zoster

disease & persons who receive clotting factor concentrates. Human papilloma virus- 3 doses up to age 26. (0, o Behavioral indications: Men who have sex with men and persons who use illegal drugs. 2, 6 months). Still recommended in those with history of HPV infection. o Occupational indications: Persons working with can start at age 9 but before becoming sexually hepatitis A virus (HAV)infected primates or with HAV in active & exposed to HPV a research laboratory setting.
Do not give if pregnant

Hepatitis A series of 2 shots o Medical indications: Persons with chronic liver

Influenza

disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver o Pneumococcus disease. One dose at or above age 65 and if it has been > 5 o Occupational indications: Health-care personnel and years since last pneumococcus vaccine & that shot public-safety workers who are exposed to blood or other was when they were <65 potentially infectious body fluids. Who begins before age 65? o Behavioral indications: Sexually active persons who Start earlier than age 65 for those with are not in a long-term, mutually monogamous Chronic lung disease (including asthma); relationship (e.g., persons with more than 1 sex partner chronic cardiovascular diseases during the previous 6 months); persons seeking diabetes mellitus evaluation or treatment for a sexually transmitted disease chronic liver diseases (STD), current or recent injection-drug users; and men cirrhosis who have sex with men. chronic alcoholism
chronic renal failure or nephrotic syndrome

In 2011, recommendation to make it universal vaccination annually for all persons 6 months and older High dose Fluzone to those over age 65

Hepatitis B series of three shots o Medical indications: Persons with end-stage renal

functional or anatomic asplenia Pneumococcus revaccination, age 19-64

o One-time revaccination after 5 yrs ages 19-64, persons w/ chronic renal failure or nephrotic syndrome functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions

o o

MMR-Measles, Mumps, Rubella

o o

Those born before 1957 are generally considered immune to measles and mumps. Second MMR (booster) recommended if born after 1957 and:
Recent exposure to measles or mumps Previously immunized w/ killed measles vaccine Vaccinated with unknown measles vaccine in year 1963-1967 Students in postsecondary educational settings Work in a health care facility Plan to travel internationally

US Preventive Services Task Force (USPSTF) o 1) Evaluating the benefits of primary and secondary preventive services in apparently healthy persons based on age, sex, and risk factors for disease o 2) Making Recommendations about which preventive services should be incorporated into primary care o Now considered by many to provide definitive standards for preventive services

What the U.S. Preventive Services Task Force Grades Mean o Grade A

Meningococcal Vaccination
o o o

Medical indications: Adults with anatomic or functional asplenia, or terminal complement component deficiencies. Meningococcal conjugate vaccine (MCV4) recommended for adults < age 55 w/ qualifying condition Meningococcal polysaccharide vacine (MPSV4) for those over age 55

Definition: USPSTF recommends service. There is high certainty that the net benefit is substantial Recommendation for Practice: Offer or provide this service. Definition: The USPSTF 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. Recommendation for Practice: Offer or provide this service Definition: The USPSTF 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. Recommendation for Practice: Offer or provide this service only if other considerations support the offering or providing the service in an individual patient. Definition: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Recommendation for Practice: Discourage the use of this service.

o Grade B

o Qualifying indications for under age 55: First-year college students in dormitories; Microbiologists routinely exposed to isolates of Neisseria meningitidis military recruits Immunization Contraindications
o Pregnancy or HIV with CD4 count <200 MMR Varicella Zoster HPV

o Grade C

o Grade D

Health Screening in Older Adults o The Guide to Clinical Preventive Services 2010-11 Recommendations of the U.S. Preventive Services Task Force

o Grade I

Definition: The USPSTF 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. Recommendation for Practice: If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Cardiovascular Recommendations o Abdominal Aortic Aneurysm Screening (2005) Recommends one-time screening for AAA by ultrasonography in men ages 65-75 who have SMOKED: o Recommends AGAINST routine screening for AAA in women.
Grade D Grade B

Cancer Recommendations Breast Cancer Screening (2009)

o o o

Recommends screening mammography every 2 years for women aged 50-74. Grade: B Used to be over 50. The evidence is insufficient to recommend for or against screening mammograms > age 75.
Grade: I

Aspirin for the Primary Prevention of Cardiovascular Events (2009) Recommends chemoprophylaxis w/ aspirin for men age 45- 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs potential harm due to Click here to Summary anenter increase in gastrointestinal hemorrhage. Recommends use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Concludes that current evidence is insufficient to assess the balance of benefits & harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. 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.
Grade: D Grade: I Grade: A

Decision to start screening mammograms before age 50 based on individual patient and their values on benefits and harms.
Grade: C

Grade: D (was I in 2009) May stop screening when there is 4yrs or less life left\

The evidence is against teaching breast selfexamination (BSE).

Grade: A 81mg is the appropriate dosage!!!

Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment & BRCA Testing (2005) o Recommends that women whose family hx is associated w/ risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing.
Grade: B

Cervical Cancer Screening (2003)

o o Strongly recommends screening for cervical cancer in sexually active women w/ a cervix.
Grade: A

Recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening w/ normal Pap smears & no high risk
Grade: D

High Blood Pressure Screening Strongly recommends that clinicians screen adults aged 18 & older for high blood pressure.
Grade: A (2007)

Recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease.
Grade: D

Lipid Disorders Screening (Men) Strongly recommends screening men aged 35 and older for lipid disorders. Recommends screening men aged 20- 35 for lipid disorders if they are at increased risk for coronary heart disease.
Grade: B (2008) Grade: A (2008)

Colorectal Cancer Screening (2008)

o

Recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50yrs & continuing to 75yrs. Risks & benefits of screening methods vary.
Grade: A

o Recommends against routine screening for

Lipid Disorders Screening (Women) Strongly recommends screening women aged 45 & older for lipid disorders if they are at increased risk for coronary heart disease. Recommends screening women aged 20-45 for lipid disorders if they are at increased risk for coronary heart disease.
Grade: B (2008) Grade: A (2008)

colorectal cancer in adults 76 to 85 yrs. There may be considerations that support colorectal cancer screening in an individual patient. Grade: C Recommends against screening for colorectal cancer in adults older than age 85 years.
Grade: D 10 yr life expectancy rule!

Infectious Disease Screening Chlamydial Infection Screening (2007)

o

Hepatitis B Virus Infection Screening

o Strongly recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit.
Grade: A (2009)

Strongly recommends that clinicians routinely screen all sexually active, non-pregnant women aged 24 years and younger and for older nonpregnant women who are at high risk.

Recommends that clinicians routinely screen all pregnant women aged 24 years & younger and older pregnant women at increased risk.
Grade: B

Grade: A

HIV Screening (2005)

o Strongly recommends that clinicians screen for (HIV) in all adolescents and adults at increased risk for HIV.
Grade: A

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.

o o

Strongly recommends that clinicians screen all pregnant women for HIV.

Gonorrhea Infection Screening (2005)

o

Grade: C Age is the most important risk marker. Other patient characteristics associated with a higher prevalence of infection include being unmarried, African-American race, having a prior history of (STD), having new or multiple sexual partners, having cervical ectopy, & using barrier contraceptives inconsistently. 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. Grade: B

Those at increased risk (as determined by prevalence rates) include: men who have had sex with men after 1975; men and women having unprotected sex with multiple partners; past or present injection drug users, men and women who exchange sex for money or drugs or have sex with partners who do; individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users; persons being treated for sexually transmitted diseases (STDs); and persons with a history of blood transfusion between 1978 and 1985. Persons who request an HIV test despite reporting no individual risk factors may also be considered at increased risk.

Grade: A

Strongly recommends prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum.

Grade: A Women and men under the age of 25including sexually active adolescents-are at highest risk for genital gonorrhea infection. Risk factors for gonorrhea include a history of previous gonorrhea infection, other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, sex work, and drug use.

Syphilis Infection Screening (2004 and 2009)

o o
Grade: A

Strongly recommends that clinicians screen persons at increased risk for syphilis infection. Strongly recommends that clinicians screen all pregnant women for syphilis infection.
Grade: A (2009) determined by incident rates) include men who have sex with men and engage in high-risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities.

o Populations at increased risk for syphilis infection (as

Endocrine Recommendations

Diabetes Mellitus in Adults, Screening for Type 2 (2008) Recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (HBA1C <7.0 or fasting sugar levels 126 or random sugar 200)
Grade B

Lifestyle Recommendations Diet, Behavioral Counseling in Primary Care to Promote a Healthy Lifestyle
o

Recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia & other known risk factors for cardiovascular & diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.
Grade: B (2003)

Osteoporosis in Postmenopausal Women, Screening (2002) o Recommends that women aged 65 and older be screened routinely for osteoporosis. This screening recommended to begin at age 60 for women at increased risk for osteoporotic fractures.
Grade: B

Breastfeeding, Behavioral Interventions to Promote

o
Grade: B (2008)

Recommends interventions during pregnancy & after birth to promote & support breastfeeding.

Obesity in Adults Screening

o

Osteoporosis Screening (DEXA scan) o The exact risk factors that should trigger screening in this age group vary. Lower body weight (weight <70 Kg) is the single best predictor of low bone mineral density. o There is less evidence to support the use of other individual risk factors (for example, smoking, weight loss, family history, decreased physical activity, alcohol or caffeine use, or low calcium and vitamin D intake, chronic steroid use) as a basis for identifying high-risk women younger than 65.

Recommends that clinicians screen all adult patients for obesity & offer intensive counseling & behavioral interventions to promote sustained weight loss for obese adults.
Grade: B (2003)

Alcohol Misuse Screening & Behavioral Counseling Intervention

o Recommends screening & behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.

Risky or hazardous drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, & more than 14 drinks per week or more than 4 drinks per occasion for men.

Grade: B (2004)

Tobacco Use & Tobacco-Caused Disease, Counseling (2009)

o

Strongly recommends that clinicians screen all adults for tobacco use & provide tobacco cessation interventions for those who use tobacco products. Grade: A o Strongly recommends that clinicians screen all pregnant women for tobacco use & provide

augmented pregnancy-tailored counseling to those who smoke. Grade: A

Other Recommendations Rh (D) Incompatibility Screening o Strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.
Grade: A (2004)

Recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks gestation, unless the biological father is known to be Rh (D)-negative.
Grade: B (2004)

Iron Deficiency Anemia Screening o Recommends routine screening for iron deficiency anemia in asymptomatic pregnant women.

Summary Multiple screening guidelines exist for different age cohorts based on evidence Reimbursement often depends on the USPSTF screening recommendation It is clinically helpful to guide your medical practice based on the current guidelines to ensure you are providing the current standard of care for your patients.

Concludes that evidence is insufficient to recommend for or against routine iron supplementation for nonanemic pregnant women or children 6-12 months at average risk for iron deficiency anemia.
Grade: I

Grade: B (2006)

Depression Screening (2009) o Recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.
Grade: B

o o

Recommends against screening if supports not in place The optimal interval for screening is unknown

Insufficient Evidence to Recommend for or Against Routine Screening For:(Rating I) Lung cancer Oral Cancer Prostate Cancer in men <75 Counseling to Prevent Skin Cancer Skin Cancer Coronary calcium for CAD in high risk population Hepatitis C (high risk individuals) Family and Intimate Partner Violence Dementia Suicide Thyroid disease Counseling to promote physical activity Glaucoma