SCREENING AND IMMUNIZATION RECOMMENDATIONS










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
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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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
  • 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]



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
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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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
  • 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]



FEMALES 40 - 49 YEARS | SCREENING
BLOOD PRESSURE
  • Screen all patients annually [2]
BREAST CANCER
  • Mammography
    • USPSTF - no recommendation for routine screening in this age group. Screening should be individualized and done every 2 years if performed. Women with a parent, sibling, or child with breast cancer are most likely to benefit from screening in this age group [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 adjunctive screening for breast cancer using breast ultrasound, magnetic resonance imaging (MRI), tomosynthesis, or other modalities in women identified to have dense breasts on an otherwise negative screening mammogram [2]
CERVICAL CANCER
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]

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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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
  • 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]



FEMALES 50 - 64 YEARS | SCREENING
BLOOD PRESSURE
  • Screen all patients annually [2]
BREAST CANCER
  • Mammography
    • USPSTF - screen every 2 years
    • 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 adjunctive screening for breast cancer using breast ultrasound, magnetic resonance imaging (MRI), tomosynthesis, or other modalities in women identified to have dense breasts on an otherwise negative screening mammogram [2]
CERVICAL CANCER
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
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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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
  • 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® and Zostavax®) Info
    • Shingrix is more effective than Zostavax, so it is recommended over Zostavax
    • Shingrix is recommended for adults ≥ 50 years. Shingrix is administered as 2 doses with the second dose given 2 - 6 months after the first.
    • Shingrix is recommended for patients who previously received the Zostavax vaccine. Shingrix should be given at least 2 months after Zostavax was given. [3]
  • 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



FEMALES ≥ 65 YEARS | SCREENING
BLOOD PRESSURE
  • Screen all patients annually [2]
BREAST CANCER
  • Mammography
    • USPSTF - screen every 2 years through age 74 then individualize the decision to continue screening
    • 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 adjunctive screening for breast cancer using breast ultrasound, magnetic resonance imaging (MRI), tomosynthesis, or other modalities in women identified to have dense breasts on an otherwise negative screening mammogram [2]
CERVICAL CANCER
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
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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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
  • 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 Vaccine - Pneumovax® 23 (PPSV23) Info
    • One time vaccination for all adults ≥ 65 years old
    • Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose.
    • Patients with certain medical problems may receive at a younger age (see early indications for more).
  • Pneumococcal Vaccine - Prevnar® 13 (PCV13) Info
    • In 2019, the CDC stopped recommending that all adults routinely receive PCV13
    • The CDC now recommends that providers discuss PCV13 with their patients and that a shared decision be made on whether to administer it. Considerations for receiving PCV13 are discussed towards the bottom of this page on the CDC website - CDC pneumonia vaccine recommendations
    • If a decision to administer both vaccines is made, the recommended schedule is provided below
    • Patients who have never received either vaccine
      • Administer PCV13 first followed by a dose of PPSV23 given ≥ 1 year later
      • If a dose of PPSV23 is inadvertently given earlier than the recommended interval, the dose need not be repeated
    • Patients who have not received PCV13 but have received a dose of PPSV23 at age 65 years or older
      • Administer PCV13 at least 1 year after the dose of PPSV23
    • Patients who have not received PCV13 but have received 1 or more doses of PPSV23 before age 65
      • Administer PCV13 at least 1 year after the most recent dose of PPSV23
      • Administer a dose of PPSV23 at least one year after PCV13 and at least 5 years after the most recent dose of PPSV23
  • Shingles Vaccine (Shingrix® and Zostavax®) Info
    • Shingrix is more effective than Zostavax, so it is recommended over Zostavax
    • Shingrix is recommended for adults ≥ 50 years. Shingrix is administered as 2 doses with the second dose given 2 - 6 months after the first.
    • Shingrix is recommended for patients who previously received the Zostavax vaccine. Shingrix should be given at least 2 months after Zostavax was given. [3]
  • 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



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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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
  • 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]



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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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
  • 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]



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]

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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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]

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
  • 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]



MALES 50 - 64 YEARS | SCREENING
BLOOD PRESSURE
  • Screen all patients annually [2]
CHOLESTEROL
  • Screen every five years [2]
COLON CANCER
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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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]

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
  • 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® and Zostavax®) Info
    • Shingrix is more effective than Zostavax, so it is recommended over Zostavax
    • Shingrix is recommended for adults ≥ 50 years. Shingrix is administered as 2 doses with the second dose given 2 - 6 months after the first.
    • Shingrix is recommended for patients who previously received the Zostavax vaccine. Shingrix should be given at least 2 months after Zostavax was given. [3]
  • 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



MALES ≥ 65 YEARS | SCREENING
BLOOD PRESSURE
  • Screen all patients annually [2]
CHOLESTEROL
  • Screen every five years [2]
COLON CANCER
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. Approximately one-third of people aged 18 - 30 years who inject illicit drugs are infected with hepatitis C, and 70% to 90% of people older than 30 years who inject illicit drugs 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]

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
  • 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 Vaccine - Pneumovax® 23 (PPSV23) Info
    • One time vaccination for all adults ≥ 65 years old
    • Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose.
    • Patients with certain medical problems may receive at a younger age (see early indications for more).
  • Pneumococcal Vaccine - Prevnar® 13 (PCV13) Info
    • In 2019, the CDC stopped recommending that all adults routinely receive PCV13
    • The CDC now recommends that providers discuss PCV13 with their patients and that a shared decision be made on whether to administer it. Considerations for receiving PCV13 are discussed towards the bottom of this page on the CDC website - CDC pneumonia vaccine recommendations
    • If a decision to administer both vaccines is made, the recommended schedule is provided below
    • Patients who have never received either vaccine
      • Administer PCV13 first followed by a dose of PPSV23 given ≥ 1 year later
      • If a dose of PPSV23 is inadvertently given earlier than the recommended interval, the dose need not be repeated
    • Patients who have not received PCV13 but have received a dose of PPSV23 at age 65 years or older
      • Administer PCV13 at least 1 year after the dose of PPSV23
    • Patients who have not received PCV13 but have received 1 or more doses of PPSV23 before age 65
      • Administer PCV13 at least 1 year after the most recent dose of PPSV23
      • Administer a dose of PPSV23 at least one year after PCV13 and at least 5 years after the most recent dose of PPSV23
  • Shingles Vaccine (Shingrix® and Zostavax®) Info
    • Shingrix is more effective than Zostavax, so it is recommended over Zostavax
    • Shingrix is recommended for adults ≥ 50 years. Shingrix is administered as 2 doses with the second dose given 2 - 6 months after the first.
    • Shingrix is recommended for patients who previously received the Zostavax vaccine. Shingrix should be given at least 2 months after Zostavax was given. [3]
  • 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





  • 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






  • 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
    • Long-term care facility residents

  • Group 3 - Immunosuppressed patients
    • HIV
    • Patients on immunosuppressive medications (e.g. chemotherapy or tumor necrosis factor-alpha inhibitors)
    • Organ transplant recipients
    • Patients with silicosis
SCREENING TESTS

  • Tuberculin Skin testing (PPD)
    • Procedure: Intradermal placement of purified protein derivative (PPD) with reading of induration in 48 - 72 hours. For screening purposes, ≥ 10 mm of induration is considered a positive test. In patients with known exposure, ≥ 5 mm of induration is considered a positive test. PPD contains > 200 M tuberculosis proteins.
    • Advantages: may be less expensive
    • Disadvantages: requires return visit; crossreacts with BCG vaccine; crossreacts with nontuberculous mycobacteria; may have booster effect with repeated dosing; readings are 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]

  • Interferon-Gamma Release Assays (IGRAs)
    • Two tests available in the U.S. - QuantiFERON®-TB Gold and T-SPOT®.TB
    • Procedure: Test is run on venous blood draw. The QuantiFERON®-TB Gold test measures the amount of interferon-gamma release and the T-SPOT®.TB test measures the amount of interferon-gamma producing cells.
      • The following values are measured on the blood:
        • nil result - amount of interferon-gamma activity in blood that has not been exposed to an antigen (control)
        • TB antigen result - amount of interferon-gamma activity in blood that has been exposed to TB antigen. The assays contain 2 - 3 antigens that are fairly specific for M tuberculosis.
        • Mitogen result - amount of interferon-gamma activity in blood that has been exposed to a nonspecific T-cell stimulator
        • TB antigen minus nil - this value is used to determine if the test is positive. A significant rise in interferon-gamma from baseline means a TB infection is likely.
        • Mitogen minus nil - this value is used to detect anergy or immune suppression
    • Advantages: does not crossreact with BCG vaccine or most nontuberculous mycobacteria (exceptions M kansasii, M szulgai, and M marinum); objective result; no booster effect with repeat testing; one visit
    • Disadvantages: more expensive; low positive or indeterminate values may occur and there is no consensus on how to manage these results; active TB may suppress interferon-gamma release
    • T-SPOT®.TB: Sensitivity - 90%; Specificity - >95%
    • QuantiFERON®-TB Gold: Sensitivity - 80%; Specificity - >95%
    • Known exposure: patients should be tested 8 - 10 weeks after their most recent known exposure [12,13,14]

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



CDC INDICATIONS FOR EARLY PNEUMONIA VACCINATION (ADULTS 19 - 64 YEARS)
PPSV23 one time
  • Alcoholism
  • Asthma
  • Cigarette smokers
  • Cirrhosis
  • Chronic heart disease (excluding hypertension)
  • Congestive heart failure
  • COPD
  • Diabetes
  • Emphysema


  • Age 65 years and older - At age 65 years or older, patients should receive PCV13 and another dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the most recent dose of PPSV23
PCV13 followed by PPSV23 at least eight weeks later
  • Cerebrospinal fluid leak
  • Cochlear implants

  • Age 65 years and older - If patient received most recent dose of PPSV23 before age 65, administer another dose of PPSV23 at age 65 years or older at least 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23
PCV13 followed by PPSV23 eight weeks later followed by PPSV23 five years later
  • Asplenic/hyposplenic
  • B- or T-lymphocyte deficiency
  • Chronic renal failure
  • Corticosteroids (long-term therapy)
  • Complement deficiencies
  • Generalized malignancy
  • Hemoglobinopathies
  • HIV infection
  • Hodgkin disease
  • Immunodeficiency - congenital or acquired
  • Immunosuppression - drug or radiation therapy
  • Leukemia
  • Lymphoma
  • Multiple myeloma
  • Nephrotic syndrome
  • Phagocytic disorders excluding chronic granulomatous disease
  • Sickle cell disease
  • Solid organ transplant


  • Age 65 years and older - If the most recent dose of PPSV23 was administered before age 65 years, at age 65 years or older, administer another dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.