Elisha L. Brownfield, MD Associate Professor of Internal Medicine Division of General Medicine/Geriatrics at MUSC

Learning Objectives Recall USPSTF prevention guidelines for adults Access and interpret the “footnotes” for the CDC adult recommended vaccines Download an App for mobile devices from the USPSTF to assist with individualization of recommendations for patients

Question Source:

MKSAP Question 1 A 30yo woman is evaluated during a routine examination in November. She received a routine Tdap booster 5 years ago. She is sexually active with a single lifetime sexual partner. She has had no history of sexually transmitted infection. She was born in the US and reports getting “routine shots” in childhood. She has had regular pap smears without abnormal results; her most recent was 3 years ago. She does not smoke cigarettes. She works as an attorney in a large corporate law firm. Findings on physical examination are unremarkable. Which of the following vaccinations should be administered? 1. Hepatitis B vaccine series 2. Human papillomavirus vaccine series 3. Influenza vaccine 4. Tetanus and diphtheria (Td) vaccine

MKSAP Question 1 A 30yo woman is evaluated during a routine examination in November. She received a routine Tdap booster 5 years ago. She is sexually active with a single lifetime sexual partner. She has had no history of sexually transmitted infection. She was born in the US and reports getting “routine shots” in childhood. She has had regular pap smears without abnormal results; her most recent was 3 years ago. She does not smoke cigarettes. She works as an attorney in a large corporate law firm. Findings on physical examination are unremarkable. Which of the following vaccinations should be administered? 1. Hepatitis B vaccine series 2. Human papillomavirus vaccine series 3. Influenza vaccine 4. Tetanus and diphtheria (Td) vaccine

Women Vaccines Fluyearly TdapTdap once; Td every 10 years Varicellaif born <1980 and never had or vaccinated HPV<26 years MMRif not vaccinated Meningococcal1 st year college living in dorms, if not vaccinated

Women 18 – 39 Counseling Alcohol Tobacco Diet/exercise/BMI Safe sex Birth control/Folate mcg qd Sun exposure Breastfeeding - pregnancy

Women H &P Screening BP (2007) Intimate partner violence – childbearing age (2013) Depression – provided staff support in place (2009)

Women Cancer screening Cervical (2012) (regardless of sexual history; not for HIV positive, immunocompromised, or history of cervical cancer or high grade cervical dysplasia/lesions) 21yo -65 yo for all q 3 years 30-65yo alternative: q 5 years with HPV Can stop at 65 if regular, negative results Can stop after hysterectomy BRCA-related cancer screening: genetic testing

Women STD screening Chlamydia screening if sexually active (2007) and <24 yo Gonorrhea screening if sexually active, and <24yo HIV screening (2013): Screen all adults 15-65yo

Women Type 2 DM (2008)Screen all adults if sustained BP >135/80

Men 18-39yo Counseling and H & P screening as above Lipids 35 yo + HIV screening (2013)Screen all adults 15-65yo Type 2 DM (2008)Screen all adults if sustained BP >135/80

Men 18-39yo Vaccines Fluyearly TdapTdap once; Td every 10 years Varicellaif born <1980 and never had or vaccinated HPV< 21 years MMRif not vaccinated Meningococcal1 st year college living in dorms

MKSAP Question 2 A 25yo woman is evaluated in October before starting a certified nursing assistant degree program. She was diagnosed with HIV infection 3 months ago. She reports having received “all my shots as a child,” and specifically recalls having chickenpox as a child. Before starting school she needs to provide proof of her immunization status. Her only medication is an oral contraceptive. Findings on physical examination are unremarkable. Which of the following is the most appropriate next step in this patient’s immunization management? 1. Administer a single measles, mumps, and rubella booster now 2. Administer live, attenuated, intranasal influenza vaccine now 3. Begin hepatitis B immunization series 4. Certify her as immune to varicella given her clinical history 5. Obtain a CD4 cell count

MKSAP Question 2 A 25yo woman is evaluated in October before starting a certified nursing assistant degree program. She was diagnosed with HIV infection 3 months ago. She reports having received “all my shots as a child,” and specifically recalls having chickenpox as a child. Before starting school she needs to provide proof of her immunization status. Her only medication is an oral contraceptive. Findings on physical examination are unremarkable. Which of the following is the most appropriate next step in this patient’s immunization management? 1. Administer a single measles, mumps, and rubella booster now 2. Administer live, attenuated, intranasal influenza vaccine now 3. Begin hepatitis B immunization series 4. Certify her as immune to varicella given her clinical history 5. Obtain a CD4 cell count

Illness Modifiers

Pregnancy Immuno-compromising conditions (excluding human immuno- deficiency virus [HIV]) HIV infection CD Men who have sex with men (MSM) Kidney failure, end-stage renal disease, receipt of hemo-dialysis Heart disease, chronic lung disease, chronic alcohol-ism Asplenia (including elective splenectomy and persistent complement component deficiencies) Chronic liver disease Diabetes Health-care personnel

Footnotes* “Evidence of immunity to varicella in adults includes any of the following: documentation of 2 doses of varicella vaccine at least 4 weeks apart; U.S.-born before 1980, except health care personnel and pregnant women; history of varicella based on diagnosis or verification of varicella disease by a health care provider; history of herpes zoster based on diagnosis or verification of herpes zoster disease by a health care provider; or laboratory evidence of immunity or laboratory confirmation of disease”

MKSAP Question 3 A 60 yo woman is evaluated during a routine examination. She has hyperlipidemia. She has a 5-pack-year smoking history but is not actively using tobacco and has no history of illicit drug use. She is married and in a monogamous relationship with her husband of 25 years. She has no family history of breast, colon, or cervical cancer. Her only medication is simvastatin. On physical examination, she is AF, BP 118/76, P74, BMI 25. Pap smear and mammography, both performed 11 months ago, were within normal limits. Which of the following conditions should also be screened for in this patient? 1. Abdominal aortic aneurysm 2. Depression 3. Hepatitis B virus infection 4. Osteoporosis

MKSAP Question 3 A 60 yo woman is evaluated during a routine examination. She has hyperlipidemia. She has a 5-pack-year smoking history but is not actively using tobacco and has no history of illicit drug use. She is married and in a monogamous relationship with her husband of 25 years. She has no family history of breast, colon, or cervical cancer. Her only medication is simvastatin. On physical examination, she is AF, BP 118/76, P74, BMI 25. Pap smear and mammography, both performed 11 months ago, were within normal limits. Which of the following conditions should also be screened for in this patient? 1. Abdominal aortic aneurysm 2. Depression 3. Hepatitis B virus infection 4. Osteoporosis

Women 40-65yo Counseling and H & P screening as above Cholesterol screeningIf at increased risk for CAD (any) Aspirin…

ASA to Prevent Cardiovascular Disease and Cancer – draft 9/14/15 Adults ages Low-dose aspirin – primary prevention of CVD and colorectal cancer 10% or greater CVD risk (ACC calculator) Not at increased risk of bleeding Life expectancy > 10 years Willing to take for 10 years

Risk factors for gastrointestinal (GI) bleeding Dose of aspirin History of GI ulcers or upper GI pain Bleeding disorders Renal failure Severe liver disease Thrombocytopenia Concurrent anticoagulation therapy or nonsteroidal anti- inflammatory drug (NSAID) use Uncontrolled hypertension Male sex Older age

Women 40-65yo Hepatitis C screening (2013)HCV screening once for all born between 1945 and 1965 HIV screening (2013)Screen all adults 15-65yo Type 2 DM (2008)Screen all adults if sustained BP >135/80

Women 40-65yo Cancer screening Cervical(as above) Colorectal cancer (2008)50+ colonoscopy, stool cards, flex sig + BE Breast cancer (2009)50+ MMG q2 years – individual basis

Lung Cancer Screening Release Date: December 2013 The USPSTF recommends annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. 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. Grade: B recommendation.B recommendation.

Lung Cancer Screening years old 30 + pack-year smoker and currently smoke OR 30 + pack-year smoker and quit within the past 15 years

Lung Cancer Screening- when to stop Achieve 15 years of smoking cessation Age 81 Substantial comorbid conditions Not a surgical candidate

Lung Cancer Screening Some patients are at higher risk than others Incidental findings were frequent Study on-going through Pulmonary

MKSAP Question 3+ A 60 yo woman is evaluated during a routine examination. She has hyperlipidemia. She has a 5-pack-year smoking history but is not actively using tobacco and has no history of illicit drug use. She is married and in a monogamous relationship with her husband of 25 years. She has no family history of breast, colon, or cervical cancer. Her only medication is simvastatin. On physical examination, she is AF, BP 118/76, P74, BMI 25. Pap smear and mammography, both performed 11 months ago, were within normal limits. Which of the following conditions should also be screened for in this patient? 1. Abdominal aortic aneurysm 2. Depression 3. Hepatitis B virus infection 4. Osteoporosis 5. Lung cancer

Women 40-65yo Vaccines Fluyearly TdapTdap once; Td every 10 years MMRif not vaccinated Zoster60+

Men 40-75yo Counseling and H & Pscreening as above HIV screening (2013)Screen all adults 15-65yo Aspirin for CVD and colorectal CA prevention AAA screening (2005)65-75yo; ever smoked; US screening once Hepatitis C screening (2013)HCV screening once for all born between 1945 and 1965

Men 40-75yo Vaccines Fluyearly TdapTdap once; Td every 10 years MMRif not vaccinated Zoster 60+ Prevnar 13 – all 65yo+. PCV 13 1 st then 23 (6-12 months) Pneumovax 23 valent once at/after 65yo If 23 first; give 13 ≥ 1 year after

Men 40-75yo Type 2 DM (2008)Screen all adults if sustained BP >135/80 Cancer screening Colorectal cancer(as above) 50+ PSA (2012)USPSTF recommends AGAINST screening Lung cancer (2013)

Women 65-75yo Counseling and H & P screening Cancer screening – consider discontinuation Hepatitis C screening (born ) Type 2 DM (sustained BP elevation) Osteoporosis screeningBone density Prevnar 13 – all 65yo+. PCV 13 1 st then 23 (6-12 months) Pneumovax 23 valent once at/after 65yo If 23 first; give 13 ≥ 1 year after

Footnotes* Revaccination with PPSV23 One-time revaccination 5 years after the first dose of PPSV23 is recommended for persons aged 19 through 64 years with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), or immunocompromising conditions. Persons who received 1 or 2 doses of PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose. No further doses of PPSV23 are needed for persons vaccinated with PPSV23 at or after age 65 years.

Prevnar 13 – disease indications Anatomical or functional asplenia CSF leaks or cochlear implants Congenital or acquired immune deficiency HIV infection Chronic renal failure or nephrotic syndrome Leukemia, Lymphoma, Hodgkin disease, generalized malignancy, multiple myeloma, Solid organ transplant Iatrogenic immunosuppression (including long-term systemic corticosteroids and radiation therapy).

Resources Vaccines: CDC.gov USPSTF – clinicians’ guide: AHRQ app: ACC risk calculator MKSAP 16 General Internal Medicine

Conclusions Frequently view recommendations from the USPSTF Study the CDC Vaccine footnotes Personalize recommendations for each patient based on risk factors Continue to discuss these recommendations with patients