SCREENING AND IMMUNIZATION RECOMMENDATIONS

• NOTE: These recommendations are for healthy adults without medical problems who are at average risk for the specified diseases. Adults with medical problems and those at increased risk for certain conditions (e.g. family history of cancer) may have different recommendations. Many organizations issue screening recommendations. In some cases, these recommendations differ. We have made an effort to include some of the more widely accepted guidelines.

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• ACRONYMS AND DEFINITIONS

• AACE - American Assoc of Clinical Endocrinologist
• AAFP - American Academy of Family Practice
• ACS - American Cancer Society
• ACP - American College of Physicians
• ADA - American Diabetes Association
• ATA - American Thyroid Association
• AUA - American Urological Association
• CDC - Center for Disease Control
• EAU - European Association of Urology
• HBV - Hepatitis B virus
• TdaP - Tetanus, diphtheria, and acellular pertussis vaccine
• MSTF - U.S. Multi-Society Task Force on Colorectal Cancer which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy
• PCV13 - Prevnar® 13 pneumonia vaccine
• PPSV23 - Pneumovax® 23 pneumonia vaccine
• PSA - Prostate specific antigen
• USPSTF - U.S. Preventive Services Task Force

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FEMALES 21 - 29 YEARS | SCREENING

BLOOD PRESSURE Screen all patients every 3 - 5 years Screen patients with risk factors annually Risk factors defined as any of the following: Initial blood pressure 130 - 139/85 - 89 mmHg African Americans Obese or overweight [2]

CERVICAL CANCER See cervical cancer screening recommendations

CHOLESTEROL Women not at increased risk - no recommendation to screen Women at increased risk - screen every 5 years Increased risk defined as presence of one of the following: Diabetes Personal history of atherosclerosis Family history of cardiovascular disease in male relatives < 50 years or female relatives < 60 years Tobacco use Hypertension Obesity (BMI ≥ 30) [2]

DIABETES USPSTF - no recommendation to screen [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea Women ≤ 24 years - screen all sexually active women. The optimal screening interval is unknown, but patients should be screened when their sexual history reveals new or persistent risk factors since the last negative test result. Women ≥ 25 years - screen women who are at increased risk (see below). The optimal screening interval is unknown, but patients should be screened when their sexual history reveals new or persistent risk factors since the last negative test result. Increased risk defined as having any of the following: History of previous STD Infection with other STD Sex partner with an STD New or multiple sex partners Sex partner who has other partners Inconsistent condom use out of a mutually monogamous relationship Exchanging sex for money or drugs Incarceration [2] HIV infection - Screen at least once in adulthood. Repeat screening per individual risk factors.

FEMALES 21 - 29 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info HPV vaccine Info Through age 26 years Never received vaccine: 3 doses at 0, 1 - 2, and 6 months Initiated series before age 15 years and received 2 doses at least 5 months apart: no more; considered complete Initiated series before age 15 years and received only 1 dose, or 2 doses less than 5 months apart: give one additional dose NOTE: Women with HIV and other immunocompromising conditions (e.g. B-lymphocyte antibody deficiencies, complete or partial T-lymphocyte defects, malignant neoplasm, transplantation, autoimmune disease, and immunosuppressive therapy) should receive a 3-dose series Age 27 - 45 years Providers should discuss potential benefits of vaccine with patients and make a shared decision. See CDC HPV vaccine considerations for a review of the benefits of HPV vaccine in adults aged 27 - 45 years. Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3]

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FEMALES 30 - 39 YEARS | SCREENING

BLOOD PRESSURE Screen all patients every 3 - 5 years Screen patients with risk factors annually Risk factors defined as any of the following: Initial blood pressure 130 - 139/85 - 89 mmHg African Americans Obese or overweight [2]

CERVICAL CANCER See cervical cancer screening recommendations

CHOLESTEROL Women not at increased risk - no recommendation to screen Women at increased risk - screen every 5 years Increased risk defined as presence of any of the following: Diabetes Personal history of atherosclerosis Family history of cardiovascular disease in male relatives < 50 years or female relatives < 60 years Tobacco use Hypertension Obesity (BMI ≥ 30) [2]

DIABETES USPSTF - screen overweight and obese adults aged 35 - 70 years every 3 years [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea Screen sexually active women who are at increased risk (see below). The optimal screening interval is unknown, but patients should be screened when their sexual history reveals new or persistent risk factors since the last negative test result. Increased risk defined as having any of the following: History of previous STD Infection with other STD Sex partner with an STD New or multiple sex partners Sex partner who has other partners Inconsistent condom use out of a mutually monogamous relationship Exchanging sex for money or drugs Incarceration [2] HIV infection - Screen at least once in adulthood. Repeat screening per individual risk factors.

FEMALES 30 - 39 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info HPV vaccine (Age 27 - 45 years) Info Providers should discuss potential benefits of vaccine with patients and make a shared decision. See CDC HPV vaccine considerations for a review of the benefits of HPV vaccine in adults aged 27 - 45 years. Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3]

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FEMALES 40 - 49 YEARS | SCREENING

BLOOD PRESSURE Screen all patients annually [2]

BREAST CANCER Mammography USPSTF - perform biennial mammography screening in women ages 40 - 74 years [2] American Cancer Society - offer screening to women between ages 40 - 44. Begin annual screening in everyone at age 45. [17] American College of Obstetricians and Gynecologists - offer screening to women in this age group. Screen every 1 - 2 years. [15] American College of Physicians - providers should discuss mammography with patients. The potential harms outweigh the benefits in most women aged 40 to 49 years. [24] American College of Radiology - screen annually starting at age 40 [18] National Health Service, United Kingdom - starting at age 47, screen every 3 years [4] Benefits and risks of mammography in average-risk women aged 40 - 49 years Breast cancer mortality: 0.58 fewer deaths per 1000 women screened a median of 7 years False-positive results: 29.4% of women will have false-positive result and 4.3% will have biopsy over 7 years of screening Overdiagnosis: 41% of identified invasive and in situ cancer cases 5 years after screening and 55% after 20 years of screening [24] Clinical breast exam (by healthcare provider) USPSTF - does not recommend [2] American Cancer Society - does not recommend [17] American College of Obstetricians and Gynecologists - perform annually [15] American College of Physicians - does not recommend [24] Self breast exam USPSTF - does not recommend [2] American Cancer Society - does not recommend [17] American College of Obstetricians and Gynecologists - does not recommend [15] Women with dense breasts The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasonography or magnetic resonance imaging (MRI) in women identified to have dense breasts on an otherwise negative screening mammogram. [2]

CERVICAL CANCER See cervical cancer screening recommendations

CHOLESTEROL Women not at increased risk - no recommendation to screen Women at increased risk - screen every 5 years Increased risk defined as presence of any of the following: Diabetes Personal history of atherosclerosis Family history of cardiovascular disease in male relatives < 50 years or female relatives < 60 years Tobacco use Hypertension Obesity (BMI ≥ 30) [2]

COLON CANCER Three organizations currently recommend screening in this age group: USPSTF - recommends everyone begin screening at 45 years old [2] American Cancer Society (ACS) - recommends everyone begin screening at 45 years old [17] US Multi-Society Task Force on Colorectal Cancer (MSTF) - recommends that African Americans begin screening at age 45 [16] See colon cancer screening recommendations in average-risk patients for recommended screening in the general population See colon cancer screening in patients at increased risk for recommended screening in high-risk populations (e.g. family history, IBD, polyps)

DIABETES USPSTF - screen overweight and obese adults aged 35 - 70 years every 3 years [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea Screen sexually active women who are at increased risk (see below). The optimal screening interval is unknown, but patients should be screened when their sexual history reveals new or persistent risk factors since the last negative test result. Increased risk defined as having any of the following: History of previous STD Infection with other STD Sex partner with an STD New or multiple sex partners Sex partner who has other partners Inconsistent condom use out of a mutually monogamous relationship Exchanging sex for money or drugs Incarceration [2] HIV infection - Screen at least once in adulthood. Repeat screening per individual risk factors.

FEMALES 40 - 49 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info HPV vaccine (Age 27 - 45 years) Info Providers should discuss potential benefits of vaccine with patients and make a shared decision. See CDC HPV vaccine considerations for a review of the benefits of HPV vaccine in adults aged 27 - 45 years. Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3]

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FEMALES 50 - 64 YEARS | SCREENING

BLOOD PRESSURE Screen all patients annually [2]

BREAST CANCER Mammography USPSTF - perform biennial mammography screening in women ages 40 - 74 years [2] American Cancer Society - screen annually from age 45 - 54. At age ≥ 55 years, screen annually or every other year. [17] American College of Obstetricians and Gynecologists - screen every 1 - 2 years [15] American College of Physicians - screen every 2 years [24] American College of Radiology - screen annually [18] National Health Service, United Kingdom - starting at age 47, screen every 3 years [4] Clinical breast exam (by healthcare provider) USPSTF - does not recommend [2] American Cancer Society - does not recommend [17] American College of Obstetricians and Gynecologists - perform annually [15] American College of Physicians - does not recommend [24] Self breast exam USPSTF - does not recommend [2] American Cancer Society - does not recommend [17] American College of Obstetricians and Gynecologists - does not recommend [15] Women with dense breasts The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasonography or magnetic resonance imaging (MRI) in women identified to have dense breasts on an otherwise negative screening mammogram. [2]

CERVICAL CANCER See cervical cancer screening recommendations

CHOLESTEROL Women not at increased risk - no recommendation to screen Women at increased risk - screen every 5 years Increased risk defined as presence of any of the following: Diabetes Personal history of atherosclerosis Family history of cardiovascular disease in male relatives < 50 years or female relatives < 60 years Tobacco use Hypertension Obesity (BMI ≥ 30) [2]

COLON CANCER See colon cancer screening recommendations in average-risk patients for recommended screening in the general population See colon cancer screening in patients at increased risk for recommended screening in high-risk populations (e.g. family history, IBD, polyps)

DIABETES USPSTF - screen overweight and obese adults aged 35 - 70 years every 3 years [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

HYPOTHYROIDISM ATA / AACE - consider screening adults ≥ 60 years old [21] USPSTF / AAFP - insufficient evidence to recommend screening [2] See hypothyroidism for more

OSTEOPOROSIS USPSTF - screen women aged 50 - 64 with DXA scanning if their 10-year risk of fracture is ≥ 9.3% (See FRAX tool to calculate risk) See osteoporosis for more

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea Screen sexually active women who are at increased risk (see below). The optimal screening interval is unknown, but patients should be screened when their sexual history reveals new or persistent risk factors since the last negative test result. Increased risk defined as having any of the following: History of previous STD Infection with other STD Sex partner with an STD New or multiple sex partners Sex partner who has other partners Inconsistent condom use out of a mutually monogamous relationship Exchanging sex for money or drugs Incarceration [2] HIV infection - Screen at least once in adulthood. Repeat screening per individual risk factors.

FEMALES 50 - 64 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3] Shingles Vaccine (Shingrix®) Info Shingrix is recommended in adults ≥ 50 years, regardless of previous herpes zoster or Zostavax vaccination. It is administered as 2 doses with the second dose given 2 - 6 months after the first (minimum interval: 4 weeks; repeat dose if administered too soon). Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer

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FEMALES ≥ 65 YEARS | SCREENING

BLOOD PRESSURE Screen all patients annually [2]

BREAST CANCER Mammography USPSTF - perform biennial mammography screening in women ages 40 - 74 years. The evidence is insufficient to make a recommendation for screening women 75 years and older. [2] American Cancer Society - screen annually or every other year. Screen as long as a woman is in good health and is expected to live ≥ 10 years. [17] American College of Obstetricians and Gynecologists - screen every 1 - 2 years through age 74 then discuss whether to continue screening [15] American College of Physicians - screen every 2 years through age 74 then discuss whether to continue screening [24] American College of Radiology - screen annually. No formal recommendation to stop. [18] National Health Service, United Kingdom - screen every 3 years up to age 73 [4] Clinical breast exam (by healthcare provider) USPSTF - does not recommend [2] American Cancer Society - does not recommend [17] American College of Obstetricians and Gynecologists - perform annually [15] American College of Physicians - does not recommend [24] Self breast exam USPSTF - does not recommend [2] American Cancer Society - does not recommend [17] American College of Obstetricians and Gynecologists - does not recommend [15] Women with dense breasts The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasonography or magnetic resonance imaging (MRI) in women identified to have dense breasts on an otherwise negative screening mammogram. [2]

CERVICAL CANCER See cervical cancer screening recommendations

CHOLESTEROL Women not at increased risk - no recommendation to screen Women at increased risk - screen every 5 years Increased risk defined as presence of any of the following: Diabetes Personal history of atherosclerosis Family history of cardiovascular disease in male relatives < 50 years or female relatives < 60 years Tobacco use Hypertension Obesity (BMI ≥ 30) [2]

COLON CANCER See colon cancer screening recommendations in average-risk patients for recommended screening in the general population See colon cancer screening in patients at increased risk for recommended screening in high-risk populations (e.g. family history, IBD, polyps)

DIABETES USPSTF - screen overweight and obese adults aged 35 - 70 years every 3 years [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

HYPOTHYROIDISM ATA / AACE - consider screening adults ≥ 60 years old [21] USPSTF / AAFP - insufficient evidence to recommend screening [2] See hypothyroidism for more

OSTEOPOROSIS USPSTF - screen all women ≥ 65 years old with DXA scan. No recommendation is made for repeat scanning. [2] See osteoporosis for more

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea Screen sexually active women who are at increased risk (see below). The optimal screening interval is unknown, but patients should be screened when their sexual history reveals new or persistent risk factors since the last negative test result. Increased risk defined as having any of the following: History of previous STD Infection with other STD Sex partner with an STD New or multiple sex partners Sex partner who has other partners Inconsistent condom use out of a mutually monogamous relationship Exchanging sex for money or drugs Incarceration [2] HIV infection - Screen at least once in adulthood. Repeat screening per individual risk factors.

FEMALES ≥ 65 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3] Pneumococcal Vaccines Info PCV13 (Prevnar 13) PCV20 (Prevnar 20) PCV15 (Vaxneuvance) PPSV23 (Pneumovax) Adults ≥ 65 years who have never received a pneumococcal vaccine One dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 ≥ 1 year later Adults with previous PPSV23 only Adults who have only received PPSV23 may receive a PCV (either PCV20 or PCV15) ≥ 1 year after their last PPSV23 dose. When PCV15 is used in those with history of PPSV23 receipt, it need not be followed by another dose of PPSV23 Adults with previous PCV13 The incremental public health benefits of providing PCV15 or PCV20 to adults who have received PCV13 only or both PCV13 and PPSV23 have not been evaluated. These adults should complete the previously recommended PPSV23 series Shingles Vaccine (Shingrix®) Info Shingrix is recommended in adults ≥ 50 years, regardless of previous herpes zoster or Zostavax vaccination. It is administered as 2 doses with the second dose given 2 - 6 months after the first (minimum interval: 4 weeks; repeat dose if administered too soon). Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer

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MALES 20 - 29 YEARS | SCREENING

BLOOD PRESSURE Screen all patients every 3 - 5 years Screen patients with risk factors annually Risk factors defined as any of the following: Initial blood pressure 130 - 139/85 - 89 mmHg African Americans Obese or overweight [2]

CHOLESTEROL Men not at increased risk - no recommendation to screen Men at increased risk - screen every 5 years starting at age 20 Increased risk defined as presence of one of the following: Diabetes Personal history of atherosclerosis Family history of cardiovascular disease in male relatives < 50 years or female relatives < 60 years Tobacco use Hypertension Obesity (BMI ≥ 30) [2]

DIABETES USPSTF - no recommendation to screen [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea USPSTF - insufficient evidence to recommend screening in men HIV infection - screen at least once in adulthood. Repeat screening per individual risk factors.

MALES 20 - 29 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info HPV vaccine Info Through age 26 years Never received vaccine: 3 doses at 0, 1 - 2, and 6 months Initiated series before age 15 years and received 2 doses at least 5 months apart: no more; considered complete Initiated series before age 15 years and received only 1 dose, or 2 doses less than 5 months apart: give one additional dose NOTE: Men who have sex with men, patients with HIV, and patients with immunocompromising conditions (e.g. B-lymphocyte antibody deficiencies, complete or partial T-lymphocyte defects, malignant neoplasm, transplantation, autoimmune disease, and immunosuppressive therapy) should receive a 3-dose series Age 27 - 45 years Providers should discuss potential benefits of vaccine with patients and make a shared decision. See CDC HPV vaccine considerations for a review of the benefits of HPV vaccine in adults aged 27 - 45 years. Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3]

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MALES 30 - 39 YEARS | SCREENING

BLOOD PRESSURE Screen all patients every 3 - 5 years Screen patients with risk factors annually Risk factors defined as any of the following: Initial blood pressure 130 - 139/85 - 89 mmHg African Americans Obese or overweight [2]

CHOLESTEROL Men not at increased risk - screen at 35 years old Men at increased risk - screen every 5 years starting at age 20 Increased risk defined as presence of one of the following: Diabetes Personal history of atherosclerosis Family history of cardiovascular disease in male relatives < 50 years or female relatives < 60 years Tobacco use Hypertension Obesity (BMI ≥ 30) [2]

DIABETES USPSTF - screen overweight and obese adults aged 35 - 70 years every 3 years [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea USPSTF - insufficient evidence to recommend screening in men HIV infection - screen at least once in adulthood. Repeat screening per individual risk factors.

MALES 30 - 39 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info HPV vaccine (Age 27 - 45 years) Info Providers should discuss potential benefits of vaccine with patients and make a shared decision. See CDC HPV vaccine considerations for a review of the benefits of HPV vaccine in adults aged 27 - 45 years. Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3]

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MALES 40 - 49 YEARS | SCREENING

BLOOD PRESSURE Screen all patients annually [2]

CHOLESTEROL Screen every five years [2]

COLON CANCER Three organizations currently recommend screening in this age group: USPSTF - recommends everyone begin screening at 45 years old [2] American Cancer Society (ACS) - recommends everyone begin screening at 45 years old [17] US Multi-Society Task Force on Colorectal Cancer (MSTF) - recommends that African Americans begin screening at age 45 [16] See colon cancer screening recommendations in average-risk patients for recommended screening in the general population See colon cancer screening in patients at increased risk for recommended screening in high-risk populations (e.g. family history, IBD, polyps)

DIABETES USPSTF - screen overweight and obese adults aged 35 - 70 years every 3 years [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

PROSTATE CANCER PSA test USPSTF - no recommendation to screen [2] AUA Average-risk men: DO NOT SCREEN African Americans and patients with a family history: consider screening from age 40 - 54 Screening interval: every two years is the preferred interval [19] ACS Men with very strong family history - consider screening men (starting at age 40) with more than one first-degree relative (father, brother, son) who had prostate cancer diagnosed at an early age (< 65 years old). Men with strong family history - consider screening men (starting at age 45) with a first-degree relative (father, brother, son) who had prostate cancer diagnosed at an early age (< 65 years old) African Americans - consider screening all African Americans starting at age 45 Screening interval: if PSA < 2.5 ng/ml, may only need to screen every 2 years. If PSA ≥ 2.5 ng/ml, screen annually. [17] Digital rectal exam (DRE) USPSTF - no recommendation made [2] AUA - does not recommend [19] ACS - PSA is recommended screening test. DRE may be part of screening. [17] See prostate cancer for more

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea USPSTF - insufficient evidence to recommend screening in men HIV infection - screen at least once in adulthood. Repeat screening per individual risk factors.

MALES 40 - 49 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info HPV vaccine (Age 27 - 45 years) Info Providers should discuss potential benefits of vaccine with patients and make a shared decision. See CDC HPV vaccine considerations for a review of the benefits of HPV vaccine in adults aged 27 - 45 years. Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3]

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MALES 50 - 64 YEARS | SCREENING

BLOOD PRESSURE Screen all patients annually [2]

CHOLESTEROL Screen every five years [2]

COLON CANCER See colon cancer screening recommendations in average-risk patients for recommended screening in the general population See colon cancer screening in patients at increased risk for recommended screening in high-risk populations (e.g. family history, IBD, polyps)

DIABETES USPSTF - screen overweight and obese adults aged 35 - 70 years every 3 years [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

HYPOTHYROIDISM ATA / AACE - consider screening adults ≥ 60 years old [21] USPSTF / AAFP - insufficient evidence to recommend screening [2] See hypothyroidism for more

OSTEOPOROSIS USPSTF - insufficient evidence to recommend screening in men [2] The Endocrine Society Screen men aged 50 - 69 if any of the following risk factors are present: History of fracture after age 50 Delayed puberty Hypogonadism Hyperparathyroidism Hyperthyroidism COPD Corticosteroid use GnRH agonists use Alcohol abuse or smoking Other causes of secondary osteoporosis (ex. rheumatoid arthritis) [20] See osteoporosis for more

PROSTATE CANCER PSA test USPSTF - consider screening in all men starting at age 55. No recommendation is made for screening interval. [2] AUA 40 - 54 years: consider screening African Americans and patients with a family history ≥ 55 years: consider screening all men Screening interval: every two years is the preferred interval [19] ACS ≥ 50 years: consider screening all men with life expectancy ≥ 10 years Screening interval: if PSA < 2.5 ng/ml, may only need to screen every 2 years. If PSA ≥ 2.5 ng/ml, screen annually. [17] Digital rectal exam (DRE) USPSTF - no recommendation made [2] AUA - does not recommend [19] ACS - PSA is recommended screening test. DRE may be part of screening.[17] See prostate cancer for more

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea USPSTF - insufficient evidence to recommend screening in men HIV infection - screen at least once in adulthood. Repeat screening per individual risk factors.

MALES 50 - 64 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3] Shingles Vaccine (Shingrix®) Info Shingrix is recommended in adults ≥ 50 years, regardless of previous herpes zoster or Zostavax vaccination. It is administered as 2 doses with the second dose given 2 - 6 months after the first (minimum interval: 4 weeks; repeat dose if administered too soon). Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer

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MALES ≥ 65 YEARS | SCREENING

BLOOD PRESSURE Screen all patients annually [2]

CHOLESTEROL Screen every five years [2]

COLON CANCER See colon cancer screening recommendations in average-risk patients for recommended screening in the general population See colon cancer screening in patients at increased risk for recommended screening in high-risk populations (e.g. family history, IBD, polyps)

DIABETES USPSTF - screen overweight and obese adults aged 35 - 70 years every 3 years [2] ADA screening recommendations - see ADA screening recs

HEPATITIS C The USPSTF recommends screening all adults 18 - 79 years old for hepatitis C. Most adults only need to be screened once. Patients with ongoing risk factors should be screened periodically. The most important risk factor for hepatitis C is injection of illicit drugs. One-third of people aged 18 to 30 who inject illicit drugs are infected with hepatitis C, and 70% to 90% of those older than 30 are infected. [2]

HYPOTHYROIDISM ATA / AACE - consider screening adults ≥ 60 years old [21] USPSTF / AAFP - insufficient evidence to recommend screening [2] See hypothyroidism for more

OSTEOPOROSIS USPSTF - insufficient evidence to recommend screening in men [2] The Endocrine Society Screen all men aged ≥ 70 years Screen men aged 50 - 69 if any of the following risk factors are present: History of fracture after age 50 Delayed puberty Hypogonadism Hyperparathyroidism Hyperthyroidism COPD Corticosteroid use GnRH agonists use Alcohol abuse or smoking Other causes of secondary osteoporosis (ex. rheumatoid arthritis) [20] See osteoporosis for more

PROSTATE CANCER PSA test USPSTF 55 - 69 years: consider screening all men ≥ 70 years: DO NOT SCREEN Screening interval: makes no recommendation [2] AUA 55 - 69 years: consider screening all men ≥ 70 years: DO NOT SCREEN Screening interval: every two years is the preferred interval [19] ACS ≥ 50 years: consider screening all men with life expectancy ≥ 10 years Screening interval: if PSA < 2.5 ng/ml, may only need to screen every 2 years. If PSA ≥ 2.5 ng/ml, screen annually. [17] Digital rectal exam (DRE) USPSTF - no recommendation made [2] AUA - does not recommend [19] ACS - PSA is recommended screening test. DRE may be part of screening.[17] See prostate cancer for more

SEXUALLY TRANSMITTED DISEASES (STDs) Chlamydia and gonorrhea USPSTF - insufficient evidence to recommend screening in men HIV infection - screen at least once in adulthood. Repeat screening per individual risk factors.

MALES ≥ 65 YEARS | IMMUNIZATIONS

COVID-19 Info Primary series: 2-dose series at 0, 4-8 weeks (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) Booster: annual booster dose Hepatitis B Info Adults aged 19 - 59 years who have not received the vaccine. Hepatitis B became part of the routine childhood immunization schedule in 1991. Adults aged 60 years and older with hepatitis B risk factors. Those without risk factors may also complete the series. Recommended hepatitis B vaccine schedules Influenza (flu shot) annually Info Measles, mumps, and rubella (MMR) Info If no evidence of past immunity, 1 - 2 doses at least 28 days apart. Number of doses will depend on indication. Evidence of immunity includes any of the following: born before 1957 (except for healthcare personnel), documented receipt of MMR, laboratory evidence of immunity [3] Pneumococcal Vaccines Info PCV13 (Prevnar 13) PCV20 (Prevnar 20) PCV15 (Vaxneuvance) PPSV23 (Pneumovax) Adults ≥ 65 years who have never received a pneumococcal vaccine One dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 ≥ 1 year later Adults with previous PPSV23 only Adults who have only received PPSV23 may receive a PCV (either PCV20 or PCV15) ≥ 1 year after their last PPSV23 dose. When PCV15 is used in those with history of PPSV23 receipt, it need not be followed by another dose of PPSV23 Adults with previous PCV13 The incremental public health benefits of providing PCV15 or PCV20 to adults who have received PCV13 only or both PCV13 and PPSV23 have not been evaluated. These adults should complete the previously recommended PPSV23 series Shingles Vaccine (Shingrix®) Info Shingrix is recommended in adults ≥ 50 years, regardless of previous herpes zoster or Zostavax vaccination. It is administered as 2 doses with the second dose given 2 - 6 months after the first (minimum interval: 4 weeks; repeat dose if administered too soon). Tetanus (Td) or Tdap every 10 years - At least one dose should be Tdap Info Varicella (chickenpox and herpes zoster) Info If no evidence of past immunity, 2 doses, 4 - 8 weeks apart Evidence of past immunity includes any of the following: Born in U.S. before 1980, history of varicella or herpes zoster, positive varicella titer

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• SMOKERS

• Abdominal aortic aneurysm (USPSTF recommendation)
• Perform a one-time screening ultrasound for abdominal aortic aneurysm in males aged 65 to 75 who have ever smoked. There is insufficient evidence to make a recommendation for female smokers. [2]

• Lung cancer screening with low-dose CT
• Recommendations from the USPSTF and ACS for lung cancer screening with low-dose CT scans are presented in the table below. Guidance is based on the NLST trial published in 2011 that found low-dose CT scan screening lowered the absolute risk of lung cancer mortality by 0.33% compared to chest X-ray screening.
• The American Lung Association (ALA) has published a webpage that provides information on lung cancer screening - ALA lung cancer screening resources

• References [2,17]

LUNG CANCER SCREENING WITH LOW-DOSE CT
USPSTF (2020) Screen patients annually who meet all of the following criteria: Age 50 - 80 ≥ 20 pack-year smoking history (1 pack-year = smoking a pack of cigarettes every day for one year; 2 pack-years = smoking 2 packs a day for one year, and so on) Currently smokes or quit within the past 15 years DURATION: Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery
ACS Screen patients annually who meet all of the following criteria: Age 55 - 74 ≥ 30 pack-year smoking history (1 pack-year = smoking a pack of cigarettes every day for one year; 2 pack-years = smoking 2 packs a day for one year, and so on) Currently smokes or quit within the past 15 years In fairly good health (defined as healthy enough for lung surgery. For example, someone on home oxygen therapy would not be a candidate.) DURATION: Screen until age 74 as long as still in fairly good health

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• SYPHILIS SCREENING

• USPSTF recommendation
• Screen at-risk individuals (see below) with a nontreponemal test (RPR or VDRL). The optimal screening interval is unknown; however, in the highest risk groups (e.g. men who have sex with men, HIV), screening every 3 - 6 months may improve detection compared to annually.
• Risk factors for syphilis include the following:
• Men who have sex with men (highest risk)
• Men and women with HIV (highest risk)
• History of incarceration, commercial sex work, or military service
• Illicit drug use, particularly methamphetamine
• Males younger than 29 years
• Race - Black > Hispanic > American Indian > Pacific Islander > White > Asian
• Southern and Western United States
• Urban > Rural

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• TUBERCULOSIS (TB)

• Reference [2,3,11]

USPSTF latent TB screening recommendations

WHOM TO SCREEN Group 1 - Patients from countries with high prevalence of TB In the U.S, more than half the foreign-born patients with active TB come from the following 5 countries: Mexico The Philippines Vietnam India China Haiti and Guatemala are also important contributors World Health Organization list of top 30 countries with highest prevalence of TB (2016 - 2020) Angola (MDR) Bangladesh (MDR) Brazil Cambodia China (MDR) Congo Central African Republic DPR Korea (MDR) DR Congo (MDR) Ethiopia (MDR) India (MDR) Indonesia (MDR) Kenya (MDR) Lesotho Liberia Mozambique (MDR) Myanmar (MDR) Namibia Nigeria (MDR) Pakistan Papua New Guinea (MDR) Philippines (MDR) Russian Federation (MDR) Sierra Leone South Africa (MDR) Thailand (MDR) The United Republic of Tanzania Vietnam (MDR) Zambia Zimbabwe (MDR) MDR - countries with a high prevalence of multidrug resistant TB Group 2 - Persons who live in, or have lived in, high-risk congregate settings Homeless Prison/correctional facilities Group 3 - Immunosuppressed patients HIV Patients on immunosuppressive medications (e.g. chemotherapy or tumor necrosis factor-alpha inhibitors) Organ transplant recipients Patients with silicosis Group 4 - People who may be exposed to active TB Healthcare workers Workers in high-risk congregate settings (e.g. prison, contact with the homeless)

• Repeat screening
• The USPSTF makes no recommendation on repeat screening. Patients at continued risk should be rescreened, but no optimal interval has been defined.

• Tuberculin Skin testing (PPD)
• Procedure: purified protein derivative (PPD), which contains more than 200 M tuberculosis proteins, is injected intradermally. Induration ≥ 10 mm at 48 - 72 hours after placement is considered a positive screening test. For patients with known exposure, induration ≥ 5 mm is considered positive.
• Advantages: may be less expensive
• Disadvantages:
• Requires return visit
• May crossreact with BCG vaccine. For patients who received the BCG vaccine in infancy and more than 10 years prior to testing, the effect is likely minimal.
• Repeated dosing can have a booster effect that causes false positives on subsequent testing
• Test interpretation is subjective
• Sensitivity (10 mm threshold): 80%
• Specificity (10 mm threshold): >95%
• Known exposure: patients should be tested 8 - 10 weeks after their most recent known exposure [12,13,26]

• Quantiferon TB Gold Plus
• Procedure: The Quantiferon TB Gold Plus test measures the amount of interferon-gamma released from T cells upon exposure to tuberculosis antigens. Infected patients have primed memory T cells that release large amounts of interferon-gamma, while uninfected patients release very little.
• Test results are based on measurements taken from 4 separate tubes of blood:
• Nil tube - the nil tube measures the amount of interferon-gamma activity in blood that has not been exposed to antigens. This provides the background interferon-gamma activity.
• Mitogen tube - the mitogen tube measures the amount of interferon-gamma activity after exposure to a nonspecific T-cell stimulator. This tube ensures that T cells are present and able to produce interferon-gamma.
• TB1 tube - the TB1 tube measures the amount of interferon-gamma release after exposure to 2 tuberculosis antigens (ESAT-6 and CFP-10), which is primarily driven by CD4 T-cell responses
• TB2 tube - the TB2 tube measures the amount of interferon-gamma release after exposure to 2 tuberculosis antigens (ESAT-6 and CFP-10) and a peptide designed to stimulate TB-specific CD8 T cells. This measures combined CD4 and CD8 T cell responses.
• Advantages:
• Does not require follow-up visit
• Does not crossreact with BCG vaccine or most nontuberculous mycobacteria (exceptions M kansasii, M szulgai, and M marinum)
• Test interpretation is objective
• There is no booster effect with repeat testing
• Disadvantages:
• May be more expensive than skin testing
• Results may be "indeterminate," which occurs when there is either a low interferon-gamma concentration from the mitogen control tube or a high interferon-gamma concentration from the nil tube. In these cases, the test should be repeated or a different test performed.
• Active TB may suppress interferon-gamma release
• Sensitivity: 90%
• Specificity: >95%
• Known exposure: patients should be tested 8 - 10 weeks after their most recent known exposure [12,13,14,26]

• T-SPOT.TB test
• Procedure: The T-SPOT.TB test measures the amount of interferon-gamma released from T cells upon exposure to tuberculosis antigens. Infected patients have primed memory T cells that release large amounts of interferon-gamma, while uninfected patients release very little. The test is performed by isolating T cells from blood and placing them in wells on a cell plate. The wells are then exposed to different factors, and interferon-gamma activity is measured.
• Nil well - the nil well measures the amount of interferon-gamma activity from cells that have not been exposed to an antigen. This provides the background interferon-gamma activity.
• Mitogen well - the mitogen well measures the amount of interferon-gamma release from cells after exposure to a nonspecific T-cell stimulator. This well ensures that T cells are present and able to produce interferon-gamma.
• Panel A well - panel A well measures the amount of interferon-gamma release after exposure to the ESAT-6 tuberculosis antigen
• Panel B well - panel B well measures the amount of interferon-gamma release after exposure to the CFP-10 tuberculosis antigen
• Advantages:
• Does not require a follow-up visit
• Does not crossreact with BCG vaccine or most nontuberculous mycobacteria (exceptions M kansasii, M szulgai, and M marinum)
• Test interpretation is objective
• There is no booster effect with repeat testing
• Disadvantages:
• May be more expensive than skin testing
• Results may come back "borderline," which occurs when the measured interferon-gamma release from Panel A or B is above the normal range but below the threshold for a positive test. In these cases, the test should be repeated or a different test performed.
• Active TB may suppress interferon-gamma release
• Sensitivity: 90%
• Specificity: >95%
• Known exposure: patients should be tested 8 - 10 weeks after their most recent known exposure [12,13,14,26]

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• PNEUMONIA VACCINE

Pneumonia vaccine recommendations in adults ≥ 65 years
Pneumococcal Vaccines PCV13 (Prevnar 13) PCV20 (Prevnar 20) PCV15 (Vaxneuvance) PPSV23 (Pneumovax) Adults ≥ 65 years who have never received a pneumococcal vaccine One dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 ≥ 1 year later Adults with previous PPSV23 only Adults who have only received PPSV23 may receive a PCV (either PCV20 or PCV15) ≥ 1 year after their last PPSV23 dose. When PCV15 is used in those with history of PPSV23 receipt, it need not be followed by another dose of PPSV23 Adults with previous PCV13 The incremental public health benefits of providing PCV15 or PCV20 to adults who have received PCV13 only or both PCV13 and PPSV23 have not been evaluated. These adults should complete the previously recommended PPSV23 series Review of pneumonia vaccine efficacy, SH article
Early indications for pneumonia vaccine (adults 19 - 64 years)
Medical conditions Patients with the following medical conditions should receive early vaccination with 1 dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 ≥ 1 years later. Vaccines do not need to be repeated at age 65 years. Alcoholism Asplenia (congenital or acquired) Asthma Cardiomyopathy Chronic liver disease Chronic lung disease Cigarette smokers Congestive heart failure COPD Diabetes Emphysema Hemoglobinopathies (e.g. thalassemia) Sickle cell disease
Immunocompromising conditions, cochlear implant, CSF leak Patients with the following medical conditions should receive early vaccination with 1 dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 ≥ 1 years later. If PCV15 and PPSV23 are given, these patients might benefit from a shorter interval between vaccines such as ≥ 8 weeks. Vaccines do not need to be repeated at age 65 years. B- or T-lymphocyte deficiency Cerebrospinal fluid leak Chronic renal failure Cochlear implants Complement deficiencies (particularly C1, C2, C3, and C4 deficiencies) Corticosteroids (long-term therapy) Generalized malignancy Hemoglobinopathies HIV infection Hodgkin disease Iatrogenic immunosuppression (immunosuppressive drugs, including long-term systemic corticosteroids and radiation therapy) Immunodeficiency - congenital or acquired Leukemia Lymphoma Multiple myeloma Nephrotic syndrome Phagocytic disorders excluding chronic granulomatous disease Solid organ transplant

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• OTHER SCREENING (NOT RECOMMENDED)

• USPSTF recommendations for other screening
• Ankle-brachial index (ABI) - insufficient evidence to recommend screening


• Carotid artery stenosis - DO NOT SCREEN. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.


• Coronary artery calcium (CAC) scoring - insufficient evidence to recommend screening


• Electrocardiography (ECG of EKG)
• Low risk of CVD (10-year risk < 10%): DO NOT SCREEN
• Intermediate or high risk of CVD: Insufficient evidence to recommend screening
• Screening for A fib: Insufficient evidence to recommend screening


• High-sensitivity C-reactive protein (hsCRP) - insufficient evidence to recommend screening


• Ovarian cancer screening - DO NOT SCREEN. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.


• Vitamin D deficiency - insufficient evidence to recommend screening

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• VACCINE INFORMATION

• Vaccine types and definitions
• Live attenuated vaccine - a live attenuated vaccine contains a living bacteria or virus that has been weakened (attenuated) in some way so that it cannot cause a harmful infection in most people. The main advantage of live attenuated vaccines is that they elicit a strong immune response, which reduces the need for boosters. The main disadvantage is that, in rare cases, they can cause a serious infection in an immunocompromised patient who either receives the vaccine or is infected by an individual who received it. Examples of live attenuated vaccines include measles, mumps, rubella, and varicella.
• Inactivated vaccines - inactivated vaccines contain a dead bacteria or virus that is incapable of causing an infection. They are safe to give to immunocompromised patients but are less immunogenic than live vaccines and, therefore, often require more boosters. Examples of inactivated vaccines include DTaP, polio, influenza shots, and rabies
• Recombinant vaccines - a recombinant vaccine is produced by taking antigen-specific DNA from a pathogen and inserting it into another organism (e.g. bacteria or yeast cell cultures). The modified organism then produces copies of the antigen for use in the vaccine. Recombinant vaccines allow for a targeted response against antigens that have been found to be vital for the pathogen's survival. They are noninfectious and safe to use in immunocompromised patients, although they often require multiple boosters. Examples of recombinant vaccines include hepatitis B, herpes zoster, and HPV.
• Messenger RNA (mRNA) vaccines - mRNA vaccines contain a piece of messenger RNA that codes for a specific antigen on the pathogen of interest. After injection, the messenger RNA is taken up by the patient's cells, where cytoplasmic ribosomes transcribe it into copies of the antigen. The antigen is then presented to white blood cells, stimulating an immune response. mRNA vaccines are unique in that they can be formulated in days, allowing for rapid testing and production. They do not cause an infection and are safe in immunocompromised patients. Examples of mRNA vaccines include the Pfizer and Moderna COVID vaccines.
• Conjugate vaccines - a conjugate vaccine joins a weak antigen to a stronger one to enhance the immune response. For example, the H. influenzae type b (Hib) vaccine contains a polysaccharide from the Hib capsule that is bound to an inactivated tetanus toxoid. Capsular polysaccharide by itself is weakly immunogenic, but the polysaccharide-toxoid complex evokes a strong response. Examples of conjugate vaccines include Hib, meningococcal, and pneumococcal (Prevnar).
• Adjuvants - adjuvants are substances added to vaccines to enhance the immune response. Common adjuvants include aluminum salts such as aluminum hydroxide, aluminum phosphate, and aluminum potassium sulfate. A CDC webpage that describes adjuvants used in FDA-approved vaccines is available here - CDC vaccine adjuvant page.

• Vaccines available in the U.S.
• List of vaccines available in U.S. (webpage) - includes vaccine type (e.g. live-attenuated, recombinant), available products, etc.
• List of vaccines available in U.S. (pdf) - includes vaccine type (e.g. live-attenuated, recombinant), available products, etc.
• U.S. vaccine information - list of U.S. vaccines with links to comprehensive information on each

• CDC immunization charts
• Childhood schedule (birth to 18 years)
• Adult schedule (19 years and older)
• Catch-up schedules (birth to 18 years)
• Medical conditions (birth to 18 years)
• Medical conditions (adults)

• Vaccine guidelines from professional organizations
• American College of Rheumatology 2022 guidelines - recommendations for rheumatology patients receiving immunosuppressants and biologics
• Advisory Committee on Immunization Practices - recommendations for patients with immunodeficiencies

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• BIBLIOGRAPHY

• 1 - American Cancer Society PAP screening guidelines 2012. PMID 22431528
• 2 - USPSTF website
• 3 - CDC website
• 4 - PMID 21916640 - NEJM review of MMG recs
• 5 - PMID 19240699 - ACG colon screen recs
• 6 - PMID 18384785 - ACS colon screen recs
• 7 - PMID 23659877 - AUA GL
• 8 - PMID 23512063 - JAMA review
• 9 - CDC rec
• 10 - PMID 26501536 - ACS breast cancer screening recs
• 11 - WHO website
• 12 - PMID 25291583 - JAMA Quantiferon Gold review
• 13 - CDC TB recommendations
• 14 - LabCorp® website
• 15 - PMID 28644335 - Breast Cancer Risk Assessment and Screening in Average-Risk Women, ACOG (2017)
• 16 - PMID 28600072 - Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer, Gastroenterology (2017)
• 17 - American Cancer Society website
• 18 - American College of Radiology website
• 19 - PMID 23659877 - EARLY DETECTION OF PROSTATE CANCER: AUA GUIDELINE, 2013, VALIDATED 2015
• 20 - PMID 22675062 Endocrine society recs in men
• 21 - PMID 22954017 - AACE 2012 Hypothyroid guidelines
• 22 - PMID 29159414 - Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention, Ann Intern Med (2017)
• 23 - CPL labs website
• 24 - PMID 30959525 - Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians, Ann Intern Med (2019)
• 25 - PMID 31683290 - Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians, Annals of Intern Med (2019)
• 26 - PMID 34879450 - Latent Tuberculosis Infection, NEJM (2021)