Primary Care: Screening and Immunization Flashcards
Primary Prevention
Preventing the health problem
The most cost-effective form of healthcare
EX: Immunizations, counseling about diet/exercise/disease prevention
Secondary Prevention
Detecting a disease in early, asymptomatic or preclinical state to minimize its impact
Ex: screening tests, such as BP check, mammo, PAP, colonoscopy
Tertiary Prevention
Minimizing negative disease-induced outcomes
ex: adjusting therapy in established disease to avoid further disease damage (like adjusting insulin dose in DM)
When to defer or delay an immunization?
Only with moderate to severe illness with or without a fever. Mild illness –> vaccinate!
Breast Cancer Screening Recommendations: Mammography: American Cancer Society (ACS)
Women 40-45 can consider annual mammogram, should offer
45-54: Annual Mammogram
55 and older: q2 years or annually if they prefer
Continue screening as long as life expectancy is 10 years or longer, or based on if would be a candidate for breast cancer treatment
Breast Cancer Screening recommendations: Mammography: USPSTF
40-49: decision to start screening should be individualized
50-74: biennial screening with mammogram
>75 evidence is insufficient to recommend for or against continued screening
When to stop Mammos: American Geriatrics Society
- Women in average-better health, with an estimated life expectancy of 5+ years, offer mammos every 1-2 years until age 85, decision should reflect risks vs harms & patient preference
- reserve screening over 85 for women in excellent health who feel strongly that they will benefit from screening (physically or mentally)
Breast Cancer Screening Recommendations: Mammography: ACOG
Offer mammos starting at age 40, annually
Initiate NO LATER than 50, either annually or biennial
No definitive age to stop, based on if they would be a candidate for treatment
Clinical Breast Exams for Breast Cancer screening:ACS
Does not recommend among average-risk women at ANY AGE
Average risk: no personal history or breast cancer, no previous radiotherapy to chest
Clinical Breast Exams for Breast Cancer screening: USPSTF
Insufficient evidence to recommend if being screened with mammo
Clinical Breast Exams for Breast Cancer: ACOG
Offer Q1-3 years 25-39, q 1 year 40+; use shared decision making as there is no clear benefit
Breast Self awareness
educate women 20 and older about breast self awareness and when to seek further evaluation
encourage women to know normal appearance and feel of their breasts so they can notice changes
no systematic or regular technique of self-exam
Colorectal Screening
Start: age 45 for men and women. Use the following tests:
- Guaiac-based fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) q1year
- Stool DNA test q 3 years
- Colonoscopy q 10 years
-Felxible sigmoidoscopy q 5 years
- CT colonography q 5 years
STOP: continue through age 75 if in good health (life expectancy > 10 y), stop at 85
abnormal non-colonscopy tests NEED f/u with colonoscopy
**Screen earlier/more frequent with risk factors: IBS, personal or family hx of colonic polyps or colon cancer, known or suspected lynch syndrome (hereditary nonpolyposis colon cancer)
Endometrial Cancer Screening
- NO routine screening test
- Educate women about risks and s/s of endometrial cancer at menopause: advise to report any unexpected bleeding, discharge, spotting –> if HAS the symptoms after menopause, then screening via endometrial biopsy
- women with hereditary non-polyposis colon cancer (HNPCC or lynch syndrome) should be offered annual screening starting at age 35 with endometrial biopsy
Lung Cancer Screening
Annual low dose computed tomography (LDCT) for:
ACS: 55-74 years in fairly good health with a 30+ pack-year smoking history, who is currently smoking or it has been 15 or less years since quitting. STOP at 75.
USPSTF: LDCT 50-80 with 20 pack year smokinb history and currently smoke or have quit within the past 15 years. Stop with low life expectancy
Cervical Cancer Screening
< 21: NO screening (if HIV+, within 1 year of initiating sex, or within 1 year of HIV+ if SA)
21-29: Cytology alone q 3 years
30-65: Cytology and HPV co-testing q 5 (preferred) OR cytology q 3; HPV q 5 is also acceptable
> 65: Stop screening if adequate prior negative screening results = 3 consecutive negative cytology results or 2 consecutive co-test results within last 10 years, most recent test within 5 years. ONCE screening has stopped, DO NOT start again, even with new sexual partner. IF history of CIN2 or higher, continue screening for 20 years after spontaneous regression or appropriate management.
Hysterectomy: No further screening necessary unless hx CIN2, CIN3, adenocarcinoma in situ or cervical cancer in last 20 years
Diabetes Screening
q 3 years starting at age 45: hgb a1c, FBS, or 2 hr GTT (75 g)
but more frequently or younger with BMI > 25 and one of the following risk factors: obesity, HTN, dyslipidemia, CVD, PCOS, physical inactivity, DM in first degree relative, AA, Asian, Hispanic, Native american, pacific islander, hx GDM/baby weighing > 9 lbs at birth
** Individuals with GDM should have LIFELONG screening at least q 3 years**
Dyslipidemia
start at 40, every 5 years, but maybe shorter if risk factors: lipid panel (total cholesterol, LDL, HDL
Osteoporosis screening
Start: 65, bone mineral density (DEXA)
*** screen postmenopausal women younger than 65 with risk factors associated with increased fracture risk: low BMI, hx of low-trauma fracture, smoking, alcohol intake 3+/day, family history of hip fracture or osteoporosis
HEP C screening
screen all individuals born between 1945-1965 once if no other risk factors
Screen others based on risk: current IVDU or intranasal drug use, blood transfusion prior to 1992, long-term hemodialysis, born to mother with HCV infection, receipt of unregulated tattoo, exposure, HIV infection
BRCA testing/screening
Recommends BRCA testing for women with a personal or family history of breast, ovarian, tubal or peritoneal cancer OR who have ancestry associated with breast cancer susceptibility 1 and 2 (BRCA 1/2) gene mutations with an appropriate brief familial risk assessment tool.
ACTIVE immunity
body creates its own antibodies, via response to exposure or vaccination
Onset of protection: 2-4 weeks
Duration of protection: years or lifelong
Passive immunity
Immunity conferred by administration of antibody produced outside of the body (like immune globulin)
Onset: within hours
Duration of protection: time-limited, usually 6-9 months
What vaccines should you avoid with a neomycin allergy
IPV, MMR, varicella
What vaccines should you avoid with streptomycin or polymixin B allergy?
IPV, smallpox
What vaccines should you avoid with baker’s yeast allergy?
Hep B
What vaccines should you avoid with gelatin allergy
MMR
What is a live attenuated vaccine?
Vaccine that has been weakened, but not dead. They cannot cause disease, but they can induce active immunity.
Examples of Live attenuated vaccines?
MMR, varicella, flumist (nasal flu vaccine only), zoster vaccine
Who should not have live vaccines?
Pregnant people, due to the theoretical risk of passing virus to unborn child
severe immunocompromise –> risk of illness
What vaccines should not be given in pregnancy?
MMR: live vaccine - theoretical risk of passing virus to unborn child; ALSO rubella = teratogen (congenital rubella syndrome, which can include developmental disability, blindness, hearing loss)
Varicella: live vaccine - theoretical risk to unborn child
HPV: insufficient safety data
Are there any vaccines that SHOULD NOT be given while breastfeeding?
NO! all are safe
Who should get HBV vaccine
Anyone who wants one, unless previously vaccinated (although revaccination will not cause harm)
Recommended to high risk groups: multiple sex partners, MSM, household contacts or sex partners of those with HBV, Intravenous drug use, healthcare workers, inmates of correctional institutions
HBV transmitted via blood to blood, sex
HBV series
0, 1, 6 months
Don’t restart series if dose is missed, give second ASAP and 3rd at least 8 weeks from 2nd
Who should get flu vaccine?
Everyone 6 months and older annually
This includes pregnant women: Risks of getting the flu (death, hospitalization, PTB) far outweigh any small risks of vaccination
SAFE in any stage of pregnancy and lactation
Who should get the pneumococcal vaccine?
PCV13 and PPSV23 everyone over 65 (PCV13 then PPSV23 1 year later)
< 65 need PCV 13 if immunocompromised, asplenia, cerebrospinal fluid leaks, cochlear implants
< 65 need PPSV23 for immunocompromised, chronic illness (asthma, DM, alcoholism), asplenia, organ or bone marrow transplant recipients, smokers, residents of nursing homes/ltc facilities
If given < 65, need one > 65 with 5 years in-between
Who should get MMR
All non-pregnant women of child-bearing age who lack evidence of immunity (vaccines or titers)
DO NOT give in pregnancy, and should not get pregnant within 4 weeks of vaccine, or immunocompromised (live)
OK for breastfeeding
Who should get Tdap?
adults who have never had this vaccine (Td, dtap, tdap): 3 dose series
Adults who have never had a tdap, but have had td/dtap need a tdap
Tdap to ALL pregnant women between 27 and 36 weeks to offer optimal protection to infant in first few months of life when high risk exists for severe illness or death from pertusis
Booster Td q 10 years for all adults
Tdap for caretakers of infants q 10 years
Who should get Varicella vaccine?
all non-pregnant adolescents and adults without evidence of immunity: 2 doses 4-8 weeks apart
OK for breastfeeding
Not OK pregnant, don’t become pregnant 4 weeks after vaccination
Who should get zoster vaccine?
All adults 50+, 2-6 months apart
Don’t give if pregnant, immunocompromised, HIV with severe immunocompromise
Who should get the Hep A vaccine?
Anyone who wants it and is not previously vaccinated
2 doses 6 months apart
Should be given to at risk: people who live in or travel to countries with high hep a, MSM, IVDU/illicit drugs, those with occupational exposure risks: food handlers, individuals with chronic liver disease or clotting factor disorders
What does the HPV vaccine protect against?
HPV 6,11 = genital warts
HPV 16,18, 31,33,52,56 = high malignancy potential together cause 90% cervical cancer
-16+18: cause 66% cervical cancer,
can cause cervical and anal cancers, also HPV 16: oropharyngeal cancer, possibly esophageal or gastric cancer
Who should get the HPV vaccine?
Routine: start 11-12 for 2 dose series, can be given as early as 9
Catch-up HPV vaccination is recommended for all people age 18-26
27-45: shared decision making (esp. new sex partners)
DO not give while pregnant, but don’t need pregnancy test prior to vaccination
HPV vaccination schedule
9-14: 2 doses 6-12 months apart
15-45: 3-dose regimen: 0, 2 months, 6 months
Who should get meningococcal vaccine?
everyone 11 or 12 years old
booster at 16 years old
all college students, asplenia, travel to high risk countries
Vision screening?
screen for acuity/glaucoma
AA age 20-39 q 3-5 years
All races 40-64 q 2-4 years
65+: q1-2 years
Persons with DM: yearly
