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Preventive Services Task Force issues new recommendations

The U.S. Preventive Services Task Force recently issued new recommendations related to screening for hepatitis C virus infection, screening for family and intimate partner violence, and use of fluoride supplements to prevent cavities in preschool children. The Task Force, the leading independent panel of private-sector experts in prevention and primary care, is chaired by Ned Calonge, M.D., Chief Medical Officer and State Epidemiologist for the Colorado Department of Public Health. The Task Force is sponsored by the Agency for Healthcare Research and Quality.

In formulating recommendations, the Task Force conducts rigorous impartial assessments of all the scientific evidence for a broad range of preventive services. Its recommendations are considered the gold standard for clinical preventive services.

The new screening recommendations and associated materials are described here. Visit the Task Force Web site at www.ahrq.gov/clinic/prevenix.htm for more information and to order copies of easy-to-read fact sheets and materials for clinicians, as well as information on earlier recommendations.

Screening for hepatitis C virus infection. Hepatitis C virus (HCV), which is primarily acquired by exposure to infected blood, can lead to cirrhosis of the liver and liver cancer, fatigue, and poorer quality of life. The Task Force recommends against routine screening for HCV infection in asymptomatic adults who are not at increased risk for infection. Patients at increased risk for HCV infection include intravenous drug users; those who had blood transfusions before 1990, when HCV screening tests became available; children of HCV-infected mothers; and, to some extent, those who engage in high-risk sexual behaviors.

The Task Force based their recommendation on a comprehensive review of the evidence on prevalence of HCV infection, antiviral treatment effectiveness, and the benefits of screening. The Task Force found good evidence that screening with available tests (initially with enzyme immunoassay and confirmation with the strip recombinant immunoblot assay) can detect HCV infection in the general population. However, the prevalence of HCV infection in the general population is low (about 2 percent), and most who are infected do not develop cirrhosis or other major negative health outcomes. In addition, there is no evidence that screening for HCV infection leads to improved long-term health outcomes, such as decreased cirrhosis of the liver, liver cancer, or death.

There is limited evidence that current treatment improves long-term health outcomes. Also, the treatment regimen is long and costly and is associated with a high patient dropout rate due to adverse effects. There is no evidence as yet that newer treatments, such as pegylated interferon plus ribavirin, can improve long-term health outcomes. Potential harms of screening include unnecessary biopsies and labeling, although there is limited evidence to determine the magnitude of these harms. The Task Force concluded that the potential harms of HCV screening in asymptomatic adults, who are not at increased risk for this infection, are likely to be greater than the potential benefits.

See "Screening for hepatitis C virus infection in adults: Recommendation statement," by the U.S. Preventive Services Task Force, in the March 16, 2004, Annals of Internal Medicine 140(6), pp. 462-464. For a detailed review of the evidence used for the recommendation, see Chou, R., Clark, E.C., and Helfand, M., "Screening for hepatitis C virus infection: A review of the evidence for the U.S. Preventive Services Task Force," in the same journal on pages 462-464.

Family and intimate partner violence. Each year in the United States about 1 million abused children are identified; 1 to 4 million women are physically, sexually, or emotionally abused by their intimate partners; and an estimated half million older adults in domestic settings are abused and/or neglected.

The Task Force comprehensively reviewed the research evidence on the performance of violence screening instruments and effectiveness of interventions based in health care settings and found no direct evidence that screening for family and intimate partner violence leads to decreased disability or premature death. The Task Force concludes there is insufficient evidence to recommend for or against routine screening.

There were no studies that focused on the accuracy of screening tools for identifying family and intimate partner violence among children, women, or older adults in the general population. The Task Force did find fair to good evidence that interventions reduce harm to children when child abuse or neglect has been assessed. However, they found limited evidence as to whether interventions reduce harm to women and no studies that examined the effectiveness of interventions in older adults.

No studies directly addressed the harms of screening and interventions for family and intimate partner violence. As a result, the Task Force could not determine the balance between the harms (for example, loss of contact with established support systems, psychological distress, and escalation of abuse) and benefits of screening for family and intimate partner violence. Although few studies provide data on detection and management to guide clinicians, the Task Force suggests that clinicians always be alert to physical and behavioral signs and symptoms associated with abuse or neglect, treat any injuries, and arrange for professional counseling for the patient. Clinicians should also provide the patient with telephone numbers of local crisis centers, shelters, and protective services agencies.

See "Screening for family and intimate partner violence: Recommendation statement," by the U.S. Preventive Services Task Force, in the March 2, 2004, Annals of Internal Medicine 140(5), pp. 382-386. For a detailed review of the evidence, see Nelson, H.D., Nygren, P., McInerney, Y., and Klein, J., "Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the U.S. Preventive Services Task Force," in the same journal, pages 387-396.

Fluoride supplements to prevent cavities in preschool children. Primary care clinicians who practice in areas where the water supply is deficient in fluoride should prescribe oral fluoride supplements to preschool children over the age of 6 months, according to a Task Force recommendation. Dental cavities are a common childhood problem affecting as many as 19 percent of children between the ages of 2 and 5 years and more than half of children ages 5 to 9 years.

The Task Force notes that primary care clinicians can play an important role in the prevention of cavities by prescribing fluoride supplements to those children whose water supplies are deficient in fluoride. Current dosage recommendations are based on the fluoride level of the local community's water supply and are available online at www.ada.org. Information on the fluoride content in a local community's water supply can be requested from local health departments. It is important for clinicians to know the fluoride levels in their patients' primary water supply before providing fluoride supplementation to avoid over-supplementation that can lead to fluorosis, which typically leads to mild discoloration of teeth.

The Task Force did not find adequate evidence that risk assessment for dental caries performed by primary care clinicians results in fewer cavities among young children. Therefore, the Task Force concluded that there was insufficient evidence to recommend for or against routine risk assessment for dental disease in preschool children by primary care clinicians. The Task Force based its conclusion on a report from a team led by James Bader, D.D.S., at AHRQ's RTI International-University of North Carolina Evidence-based Practice Center.

See "Prevention of dental caries in preschool children: Recommendations and rationale," in the May 2004 American Journal of Preventive Medicine 26(4), pp. 326-329. For a detailed review of the evidence, see "Physicians' roles in preventing dental caries in preschool children: A summary of the evidence for the U.S. Preventive Services Task Force," in the same journal, pages 315-325.

Editor's note: All Task Force recommendations and supporting materials are available online at www.ahrq.gov/clinic/prevenix.htm.

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