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US Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd edition. Baltimore (MD): Williams & Wilkins; 1996.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd edition.

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iiiThe Periodic Health Examination: Age-Specific Charts

The periodic health visit is an important opportunity for the delivery of clinical preventive services. Identification of specific preventive services that are appropriate for inclusion in the periodic health examination has been one of the principal objectives of the U.S. Preventive Services Task Force project. The process by which these determinations were made is discussed in detail in Chapter ii. This chapter explores the services that were evaluated by the Task Force and are recommended as part of the periodic health examination of the asymptomatic individual. It includes a series of five tables listing specific preventive services that are recommended for patients in different age groups. Conditions that are likely to benefit from early identification but that are not considered appropriate for routine screening are listed in Table 6. Disorders appearing in this table are often overlooked by clinicians due to failure to recognize suggestive signs or symptoms. For example, child abuse may not be diagnosed if physical findings suggestive of abuse are overlooked during routine or symptomatic examinations. 1

Table 6. Conditions for Which Clinicians Should Remain Alert.

Table

Table 6. Conditions for Which Clinicians Should Remain Alert.

The Task Force judged it especially important to emphasize those preventive services that have been proven to be effective in properly conducted studies, and to tailor the content of the periodic health examination to the individual needs of the patient. This approach is based on the recognition that the limited time afforded to patient encounters may be most constructively used if the clinician focuses on interventions of proven efficacy. The clinician can then choose from among these effective interventions for each patient according to the likeliest causes of illness and injury based on that individual's age, sex, and other risk factors. Thus, the two most important factors to consider are the potential effectiveness of clinical interventions in improving clinical outcomes and the leading causes of mortality and morbidity.

Clinical efforts directed toward promoting health and preventing disease are of limited value if the preventive intervention does not improve outcome. Thus, the major consideration in setting priorities is effectiveness of the intervention. Although suicide and homicide are important causes of death among adolescents, for example, the effectiveness of efforts by primary care clinicians to prevent deaths from intentional injuries has not been established (see Chapters 50 and 59). On the other hand, there are effective measures to reduce the risk of motor vehicle injuries, a leading cause of death in this age group. Proper use of safety belts has been shown to reduce the risk of injury and death from motor vehicle crashes by as much as 40-60%.2-5 Alcohol intoxication is associated with nearly half of all fatal crashes. 6 With one of three deaths among young persons occurring in motor vehicle crashes, 7 the busy clinician seeing adolescent patients is best advised to direct attention to the use of safety belts and the dangers of driving while under the influence of alcohol, rather than to interventions of unproven effectiveness. For each recommendation in Tables 1- 5, the reader is urged to refer to appropriate chapters in the text to obtain detailed information about the scientific rationale.

It is also important to consider the leading causes of morbidity and mortality for patients when establishing priorities for the periodic health examination. For example, a clinician wishing to practice prevention during the few remaining minutes of an office visit with a 56-year-old female might consider a number of different counseling interventions that are effective in changing behavior, such as counseling about reducing dietary fat or avoiding high-risk sexual behavior. A 56-year-old female is considerably more likely to die from cardiac disease than from HIV or other sexually transmitted diseases. For women age 55-64 years in the U.S. during 1993, the death rate due to heart disease was 204/100,000, making it the second leading cause of death. HIV, on the other hand, is not even among the 10 leading causes of death for women of that age group. 7 It seems clear on the basis of mortality data alone that a few minutes with such a patient might be more productively spent by discussing dietary fat. Leading causes of death by age group are provided for each table.

While more difficult to measure than mortality, leading causes of morbidity also should guide the use of preventive services. The adolescent population provides a clear example. Over 60% of gonococcal infections occur in persons under age 25. 8 The prevalence of chlamydial infection is highest among young women age 15-19. 9 Each year in the U.S., about 1 million adolescent females aged 15-19 (about 8-10% of this age group) and nearly 30,000 girls under age 15 become pregnant. 10 Thus, encounters with the adolescent population should target unintended pregnancy and sexually transmitted diseases as important causes of morbidity in this age group. Essential hypertension, neoplasms, and problem drinking account for a large number of office and outpatient department visits in older patients,11-13 while injuries and poisonings account for 32% of emergency room visits among the general population. 14 Among elderly patients, commonly reported causes of chronic morbidity include visual and hearing impairments. 11

Individual risk factors are also important to consider in designing the periodic health examination. The leading causes of morbidity and mortality may differ considerably for persons in special high-risk groups as compared to individuals of the same age and sex in the general population. For example, minority children in central cities are 6 times as likely as non-urban non-minority children to have elevated blood lead levels. 15 Therefore, periodic health examinations for members of this high-risk population should include activities to prevent lead exposure, including screening. Injection drug use is also uncommon in the general population, but among individuals with this history, acquired immunodeficiency syndrome (AIDS) is the leading cause of death 16 and hepatitis B is an important cause of morbidity and mortality. Thus, essential preventive interventions in the periodic health examination of an injection drug user are counseling about measures to prevent transmission of HIV and other infectious diseases and immunization against hepatitis B virus. The differences in priorities among individuals in different age groups and risk categories and the varying effectiveness of some preventive services in different populations make it impossible to recommend a uniform periodic health examination for all persons.

Many of the preventive services appearing in Tables 1- 5 are recommended only for members of high-risk groups. These are listed separately in the lower half of each table and are grouped by general patient characteristics that broadly define high-risk populations. This organization will help the clinician to identify patients who might be eligible for one or more of the interventions listed. It is crucial, however, to then read the specific high-risk definition indicated by an annotated high-risk (HR) code after each intervention, because patients may share characteristics of the general high-risk grouping without actually meeting the individual high-risk definitions for every intervention within that group. For example, a 23-year-old woman whose high-risk sexual behavior is limited to having two recent sexual partners should be screened for gonorrhea and chlamydia infection, but she may not require screening for syphilis or a hepatitis A vaccine. To avoid providing unnecessary preventive services, clinicians must evaluate carefully whether patients who are potentially at risk meet the specific high-risk definitions for each potential intervention. While nonstandardized historical questions were not evaluated by the Task Force and therefore are not included in the tables, the history and physical examination can be used to identify high-risk individuals who would benefit from targeted interventions. Appropriate chapters in the text provide more detailed guidelines to help identify individuals at increased risk.

Task Force recommendations can be compared with those of other major organizations and government agencies, which are listed in each chapter under the heading Recommendations of Other Groups. In addition, the Clinical Interventionsection contains detailed recommendations and, in many cases, concise information for the clinician on: conditions to remain alert for, anticipatory guidance, currently recommended techniques, drug dosages, and other specifics for performing recommended preventive services. It is not the intent of the Guideto supply comprehensive information on how to provide these preventive services. The interested reader is referred to the U.S. Public Health Service's prevention implementation program, "Put Prevention Into Practice," 17 and to other published sources on the implementation of clinical preventive services. 18

The preventive services examined in this report and appearing in Tables 1- 5 include only those preventive services that might be performed by primary care clinicians on asymptomatic persons in the context of routinehealth care (see Chapter ii). Preventive measures involving persons with signs or symptoms and those performed outside the clinical setting are not within the scope of this report or its recommendations. While the Task Force did not evaluate all components of the physical examination, several specific screening maneuvers that might be performed as part of the physical examination are included if they were considered. The tables are not intended as a complete list of all that should occur during the periodic health examination. Rather, these recommendations encompass those preventive services that have been examined by the Task Force and that have been shown to have satisfactory evidence of clinical effectiveness, based on the methodology discussed in the preceding chapter.

At the same time, the preventive interventions listed are not exhaustive. The periodic health examination performed by most pediatricians, for example, includes a number of maneuvers that were not examined by the Task Force, such as screening for developmental disorders and anticipatory guidance the interested reader can refer to the recommendations of other groups for further information on such topics.19-21 Similarly, Task Force recommendations relating to preventive services during pregnancy should not be interpreted as comprehensive guidelines for prenatal care.

Preventive services listed in each table are not necessarily recommended at every periodic visit. For example, although sigmoidoscopy is recommended for persons age 50 and over, it is not recommended annually even though periodic visits in this age group may occur once a year. Where a specific periodicity has been proven effective (e.g., annual fecal occult blood testing in persons 50 years of age and over), this information is included in the footnotes for each table. The Task Force has not attempted to design a periodicity schedule for health supervision visits because for many interventions, evidence of an optimal periodicity is lacking. In addition, periodicity for certain interventions varies with patient characteristics (age, gender, risk factors).

Although the preventive services listed in Tables 1- 5 can serve as the basis for designing periodic checkups devoted entirely to health promotion and disease prevention, they may also be performed during visits for other reasons (e.g., illness visits, chronic disease checkups) when indicated. Health maintenance needs to be considered at every visit. For patients with limited access to care, the illness visit may provide the only realistic opportunity to discuss prevention. It is recognized that busy clinicians may not be able to perform all recommended preventive services during a single clinical encounter. Indeed, it is not clear that such a grouping is either necessary or clinically effective. If a sparser, evidence-based protocol is used, health maintenance can frequently be done during acute visits. Patients suffering from an acute illness or injury, however, may not be receptive to some preventive interventions. The clinician must therefore use discretion in selecting appropriate preventive services from these tables and may wish to give special emphasis to those effective interventions aimed at the leading causes of illness and disability in the age group. Recommended preventive services that cannot be performed by the clinician at the current visit should be scheduled for a later health visit.

Immunizations appearing in Tables 1-5 are those recommended on a routine basis and do not apply to persons with special exposures to infected individuals. The reader is referred to Chapter 67 for detailed guidelines on immunizations in such circumstances.

Tables 1- 5do not include interventions for which the Task Force found insufficient evidence on which to base recommendations for or against inclusion in the periodic health examination (i.e., "C" recommendations). The Task Force recognizes that there may be other grounds on which to base a recommendation for or against an intervention when scientific evidence is not available, including patient preference, costs associated with the procedure, the likelihood of benefit or harms from the procedure, and the burden of suffering from the condition. Consideration of these other grounds can guide the clinician in making decisions about the appropriate use of these interventions. The reader is referred to Chapter ii for detailed discussion of the development of "C" recommendations. For many important causes of morbidity and mortality, evidence of effective preventive interventions is lacking. There is a great need for well-controlled, randomized studies with adequate sample sizes to evaluate the effectiveness of preventive interventions for many conditions. Such topics merit attention in the planning of future research agendas.

The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by Ann O'Malley, MD, MPH, and Carolyn DiGuiseppi, MD, MPH.

Table 1. Birth to 10 Years

Table 1. Birth to 10 Years.

Table

Table 1. Birth to 10 Years.

  • HR1 =
  • Infants age 6-12 mo who are: living in poverty, black, Native American or Alaska Native, immigrants from developing countries, preterm or low birth weight infants, or infants whose principal dietary intake is unfortified cow's milk (see Ch. 22).
  • HR2 =
  • Infants born to high-risk mothers whose HIV status is unknown. Women at high risk include: past or present injection drug use persons who exchange sex for money or drugs, and their sex partners injection drug-using, bisexual, or HIV-positive sex partners currently or in past persons seeking treatment for STDs blood transfusion during 1978-1985 (see Ch. 28).
  • HR3 =
  • Persons infected with HIV, close contacts of persons with known or suspected TB, persons with medical risk factors associated with TB, immigrants from countries with high TB prevalence, medically underserved low-income populations (including homeless), residents of long-term care facilities (see Ch. 25). See Ch. 25 for indications for BCG vaccine.
  • HR4 =
  • Persons >=2 yr living in or traveling to areas where the disease is endemic and where periodic outbreaks occur (e.g., countries with high or intermediate endemicity certain Alaska Native, Pacific Island, Native American, and religious communities). Consider for institutionalized children aged >=2 yr. Clinicians should also consider local epidemiology (see Ch. 65-67).
  • HR5 =
  • Immunocompetent persons >=2 yr with certain medical conditions, including chronic cardiac or pulmonary disease, diabetes mellitus, and anatomic asplenia. Immunocompetent persons >=2 yr living in high-risk environments or social settings (e.g., certain Native American and Alaska Native populations) (see Ch. 66).
  • HR6 =
  • Annual vaccination of children >=6 mo who are residents of chronic care facilities or who have chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction (see Ch. 66). See Ch. 66 for indications for amantadine/rimantadine prophylaxis.
  • HR7 =
  • Children about age 12 mo who: 1) live in communities in which the prevalence of lead levels requiring individual intervention, including residential lead hazard control or chelation, is high or undefined 2) live in or frequently visit a home built before 1950 with dilapidated paint or with recent or ongoing renovation or remodeling 3) have close contact with a person who has an elevated lead level 4) live near lead industry or heavy traffic 5) live with someone whose job or hobby involves lead exposure 6) use lead-based pottery or 7) take traditional ethnic remedies that contain lead (see Ch. 23).
  • HR8 =
  • Children living in areas with inadequate water fluoridation (<0.6 ppm) (see Ch. 61).
  • HR9 =
  • Persons with a family history of skin cancer, a large number of moles, atypical moles, poor tanning ability, or light skin, hair, and eye color (see Ch. 12).

Table 2. Ages 11-24 Years

Table 2. Ages 11-24 Years.

Table

Table 2. Ages 11-24 Years.

  • HR1 =
  • Persons who exchange sex for money or drugs, and their sex partners persons with other STDs (including HIV) and sexual contacts of persons with active syphilis. Clinicians should also consider local epidemiology (see Ch. 26).
  • HR2 =
  • Females who have: two or more sex partners in the last year a sex partner with multiple sexual contacts exchanged sex for money or drugs or a history of repeated episodes of gonorrhea. Clinicians should also consider local epidemiology (see Ch. 27).
  • HR3 =
  • Males who had sex with males after 1975 past or present injection drug use persons who exchange sex for money or drugs, and their sex partners injection drug-using, bisexual, or HIV-positive sex partner currently or in the past blood transfusion during 1978-1985 persons seeking treatment for STDs. Clinicians should also consider local epidemiology (see Ch. 28).
  • HR4 =
  • Sexually active females with multiple risk factors including: history of prior STD new or multiple sex partners age under 25 nonuse or inconsistent use of barrier contraceptives cervical ectopy. Clinicians should consider local epidemiology of the disease in identifying other high-risk groups (see Ch. 29).
  • HR5 =
  • Persons living in, traveling to, or working in areas where the disease is endemic and where periodic outbreaks occur (e.g., countries with high or intermediate endemicity certain Alaska Native, Pacific Island, Native American, and religious communities) men who have sex with men injection or street drug users. Vaccine may be considered for institutionalized persons and workers in these institutions, military personnel, and day-care, hospital, and laboratory workers. Clinicians should also consider local epidemiology (see Ch. 66,67).
  • HR6 =
  • HIV positive, close contacts of persons with known or suspected TB, health care workers, persons with medical risk factors associated with TB, immigrants from countries with high TB prevalence, medically underserved low-income populations (including homeless), alcoholics, injection drug users, and residents of long-term care facilities (see Ch. 25). See Ch. 25 for indications for BCG vaccine.
  • HR7 =
  • Persons who continue to inject drugs (see Ch. 53).
  • HR8 =
  • Immunocompetent persons with certain medical conditions, including chronic cardiac or pulmonary disease, diabetes mellitus, and anatomic asplenia. Immunocompetent persons who live in high-risk environments or social settings (e.g., certain Native American and Alaska Native populations) (see Ch. 66).
  • HR9 =
  • Annual vaccination of: residents of chronic care facilities persons with chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction and health care providers for high-risk patients (see Ch. 66). See Ch. 66 for indications for amantadine/rimantadine prophylaxis.
  • HR10 =
  • Adolescents and young adults in settings where such individuals congregate (e.g., high schools and colleges), if they have not previously received a second dose (see Ch. 65, 66).
  • HR11 =
  • Healthy persons aged >=13 yr without a history of chickenpox or previous immunization. Consider serologic testing for presumed susceptible persons aged >=13 yr (see Ch. 65, 66).
  • HR12 =
  • Persons born after 1956 who lack evidence of immunity to measles or mumps (e.g., documented receipt of live vaccine on or after the first birthday, laboratory evidence of immunity, or a history of physician-diagnosed measles or mumps) (see Ch. 65, 66).
  • HR13 =
  • Persons with a family or personal history of skin cancer, a large number of moles, atypical moles, poor tanning ability, or light skin, hair, and eye color (see Ch. 12).
  • HR14 =
  • Women with prior pregnancy affected by neural tube defect who are planning pregnancy (see Ch. 42).
  • HR15 =
  • Persons aged <17 yr living in areas with inadequate water fluoridation (<0.6 ppm) (see Ch. 61).

Table 3. Ages 25-64 Years

Table 3. Ages 25-64 Years.

Table

Table 3. Ages 25-64 Years.

  • HR1 =
  • Persons who exchange sex for money or drugs, and their sex partners persons with other STDs (including HIV) and sexual contacts of persons with active syphilis. Clinicians should also consider local epidemiology (see Ch. 26).
  • HR2 =
  • Women who exchange sex for money or drugs, or who have had repeated episodes of gonorrhea. Clinicians should also consider local epidemiology (see Ch. 27).
  • HR3 =
  • Men who had sex with men after 1975 past or present injection drug use persons who exchange sex for money or drugs, and their sex partners injection drug-using, bisexual, or HIV-positive sex partner currently or in the past blood transfusion during 1978-1985 persons seeking treatment for STDs. Clinicians should also consider local epidemiology (see Ch. 28).
  • HR4 =
  • Sexually active women with multiple risk factors including: history of STD new or multiple sex partners nonuse or inconsistent use of barrier contraceptives cervical ectopy. Clinicians should also consider local epidemiology (see Ch. 29).
  • HR5 =
  • Blood product recipients (including hemodialysis patients), persons with frequent occupational exposure to blood or blood products, men who have sex with men, injection drug users and their sex partners, persons with multiple recent sex partners, persons with other STDs (including HIV), travelers to countries with endemic hepatitis B (see Ch. 66).
  • HR6 =
  • Persons living in, traveling to, or working in areas where the disease is endemic and where periodic outbreaks occur (e.g., countries with high or intermediate endemicity certain Alaska Native, Pacific Island, Native American, and religious communities) men who have sex with men injection or street drug users. Consider for institutionalized persons and workers in these institutions, military personnel, and day-care, hospital, and laboratory workers. Clinicians should also consider local epidemiology (see Ch. 66, 67).
  • HR7 =
  • HIV positive, close contacts of persons with known or suspected TB, health care workers, persons with medical risk factors associated with TB, immigrants from countries with high TB prevalence, medically underserved low-income populations (including homeless), alcoholics, injection drug users, and residents of long-term care facilities (see Ch. 25). See Ch. 25 for indications for BCG vaccine.
  • HR8 =
  • Persons who continue to inject drugs (see Ch. 53).
  • HR9 =
  • Immunocompetent institutionalized persons aged >=50 yr and immunocompetent persons with certain medical conditions, including chronic cardiac or pulmonary disease, diabetes mellitus, and anatomic asplenia. Immunocompetent persons who live in high-risk environments or social settings (e.g., certain Native American and Alaska Native populations) (see Ch. 66).
  • HR10 =
  • Annual vaccination of residents of chronic care facilities persons with chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction and health care providers for high-risk patients (Ch. 66). See Ch. 66 for indications for amantadine/rimantadine prophylaxis.
  • HR11 =
  • Persons born after 1956 who lack evidence of immunity to measles or mumps (e.g., documented receipt of live vaccine on or after the first birthday, laboratory evidence of immunity, or a history of physician-diagnosed measles or mumps) (see Ch. 66).
  • HR12 =
  • Healthy adults without a history of chickenpox or previous immunization. Consider serologic testing for presumed susceptible adults (see Ch. 65, 66).
  • HR13 =
  • Persons with a family or personal history of skin cancer, a large number of moles, atypical moles, poor tanning ability, or light skin, hair, and eye color (see Ch. 12).
  • HR14 =
  • Women with previous pregnancy affected by neural tube defect who are planning pregnancy (see Ch. 42).

Table 4. Age 65 and Older

Table 4. Age 65 and Older.

Table

Table 4. Age 65 and Older.

  • HR1 =
  • HIV positive, close contacts of persons with known or suspected TB, health care workers, persons with medical risk factors associated with TB, immigrants from countries with high TB prevalence, medically underserved low-income populations (including homeless) or living in a shelter, alcoholics, injection drug users, and residents of long-term care facilities (see Ch. 25). See Ch. 25 for indications for BCG vaccine.
  • HR2 =
  • Persons living in, traveling to, or working in areas where the disease is endemic and where periodic outbreaks occur (e.g., countries with high or intermediate endemicity certain Alaska Native, Pacific Island, Native American, and religious communities) men who have sex with men injection or street drug users. Consider for institutionalized persons and workers in these institutions, and hospital and laboratory workers. Clinicians should also consider local epidemiology (see Ch. 66,67).
  • HR3 =
  • Men who had sex with men after 1975 past or present injection drug use persons who exchange sex for money or drugs, and their sex partners injection drug-using, bisexual, or HIV-positive sex partner currently or in the past blood transfusion during 1978-1985 persons seeking treatment for STDs. Clinicians should consider local epidemiology (see Ch. 28).
  • HR4 =
  • Consider for persons who have not received the vaccine or are vaccinated late when the vaccine may be ineffective due to major antigenic changes in the virus for unvaccinated persons who provide home care for high-risk persons to supplement protection provided by vaccine in persons who are expected to have a poor antibody response and for high-risk persons in whom the vaccine is contraindicated (see Ch. 66).
  • HR5 =
  • Persons aged 75 years and older or aged 70-74 with one or more additional risk factors including: use of certain psychoactive and cardiac medications (e.g., benzodiazepines, antihypertensives) use of >=4 prescription medications impaired cognition, strength, balance, or gait. Intensive individualized home-based multifactorial fall prevention intervention is recommended in settings where adequate resources are available to deliver such services (see Ch. 58).
  • HR6 =
  • Although evidence is insufficient to recommend routine screening in elderly persons, clinicians should consider cholesterol screening on a case-by-case basis for persons ages 65-75 with additional risk factors (e.g., smoking, diabetes, or hypertension) (see Ch. 2).
  • HR7 =
  • Persons with a family or personal history of skin cancer, a large number of moles, atypical moles, poor tanning ability, or light skin, hair, and eye color (see Ch. 12).
  • HR8 =
  • Blood products recipients (including hemodialysis patients), persons with frequent occupational exposure to blood or to blood products, men who have sex with men, injection drug users and their sex partners, persons with multiple recent sex partners persons with other STDs (including HIV), travelers to countries with endemic hepatitis B (see Ch. 66).
  • HR9 =
  • Persons who exchange sex for money or drugs and their sex partners persons with other STDs (including HIV) and sexual contacts of persons with active syphilis. Clinicians should also consider (see Ch. 26).
  • HR10 =
  • Persons who continue to inject drugs (see Ch. 53).(High Risk Codes,Table 4.Age 65 and older, continued)
  • HR11 =
  • Healthy adults without a history of chickenpox or previous immunization. Consider serologic testing may be considered for presumed susceptible adults (see Ch. 65,66).

Table 5. Pregnant Women [**]

Table 5. Pregnant Women [**].

Table

Table 5. Pregnant Women [**].

  • HR1 =
  • Women with history of STD or new or multiple sex partners. Clinicians should also consider local epidemiology. Chlamydia screen should be repeated in 3rd trimester if at continued risk (see Ch. 29).
  • HR2 =
  • Women under age 25 with two or more sex partners in the last year, or whose sex partner has multiple sexual contacts women who exchange sex for money or drugs and women with a history of repeated episodes of gonorrhea. Clinicians should also consider local epidemiology. Gonorrhea screen should be repeated in the 3rd trimester if at continued risk (see Ch. 27).
  • HR3 =
  • In areas where universal screening is not performed due to low prevalence of HIV infection, pregnant women with the following individual risk factors should be screened: past or present injection drug use women who exchange sex for money or drugs injection drug-using, bisexual, or HIV-positive sex partner currently or in the past blood transfusion during 1978-1985 persons seeking treatment for STDs (see Ch. 28).
  • HR4 =
  • Women who are initially HBsAg-negative who are at high risk due to injection drug use, suspected exposure to hepatitis B during pregnancy, multiple sex partners (see Ch. 24).
  • HR5 =
  • Women who exchange sex for money or drugs, women with other STDs (including HIV), and sexual contacts of persons with active syphilis. Clinicians should also consider local epidemiology (see Ch. 26).
  • HR6 =
  • Women who continue to inject drugs (see Ch. 53).
  • HR7 =
  • Unsensitized D-negative women (see Ch. 38).
  • HR8 =
  • Prior pregnancy affected by Down syndrome, advanced maternal age (>=35 yr), known carriage of chromosome rearrangement (see Ch. 41).
  • HR9 =
  • Women with previous pregnancy affected by neural tube defect (see Ch. 42).

Table 6. Conditions for Which Clinicians Should Remain Alert

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