Health Promotion, Screening, Disease Prevention, Adolescent and Adult

• Leading cause of death (all ages/sexes):

  • Heart disease (female \text{22\%}, male \text{24\%})

  • Cancer (female \text{21\%}, male \text{22\%})

  • Accidents/unintentional injuries

• Cancer Mortality: Top three cancer deaths (all ages/sexes):

  • Lung and bronchus

  • Colon and rectum

  • Pancreas

• Cancer is more common in older adults; \text{80\%} of all cancers in the United States are diagnosed in people age 55\text{ years} or older.

• Leading Causes of Death in Adolescents:

  • Death rate for teen males is higher than for teen females:

  • Unintentional injuries; most common cause is motor vehicle crashes (risk is highest from 16\to\19\text{ years} of age).

  • Suicide; watch for signs of depression, such as talking about suicide, saying goodbye to friends and family, social isolation, social media updates about death. Interview teen with parent, then alone (without parent). Refer to psychiatrist/therapist for further evaluation.

  • Homicide; nonfatal and fatal violence are much higher among young people compared with any other age group.

• Leading Causes of Mortality by Age Group:

  • Birth to 12 months: Congenital malformations

  • Age 1 to 44 years: Unintentional injuries

  • Age 45 to 64 years: Cancer

  • Age 65 years and older: Heart disease

• Life Expectancy:

  • In 2021, average life expectancy in the United States was 76.4\text{ years}: 73.5\text{ years} for males and 79.3\text{ years} for females.

Cancer Statistics and Notes

• The most common cancer is skin cancer. The most common type of skin cancer is basal cell carcinoma; melanoma causes the majority of skin cancer deaths.

• Most common cancer by sex (prevalence):

  • Men: Prostate cancer. In men, there are more cases of prostate cancer (prevalence), but the cancer that causes the most deaths (mortality) is lung cancer. African American men and Caribbean men of African ancestry are at higher risk for prostate cancer; a first-degree relative (father or brother) with prostate cancer at age younger than 65 years is a risk factor.

  • Women: Breast cancer. In women, there are more cases of breast cancer (prevalence), but the cancer that causes the most deaths (mortality) is lung cancer.

• Real-world relevance: risk factors include family history (first-degree relative), race/ethnicity (e.g., African descent for prostate cancer risk).

Screening Tests and Key Concepts

• Sensitivity: A sensitive test is very good at identifying/detecting those people who have the disease (true positive).

  • Mnemonic: “sensitivity—rule in” or “SIN.”

• Specificity: A specific screening test is very good at identifying/detecting those people without the disease (true negative).

  • Mnemonic: “specificity—rule out” or “SPOUT.”

• Examples of screening tests (selected):

  • Pap smears, mammograms, complete blood count (for anemia)

  • Screening for depression (interview about feelings of sadness, hopelessness)

  • Screening for sexually transmitted infections (STIs): e.g., chlamydia and gonorrhea; assess sexual history and partners and signs/symptoms

  • Screening for alcohol use disorder (CAGE questionnaire)

  • Testing for hepatitis C virus (anti-HCV) for all adults 18\leq\text{age}<80 years and for persons with risk factors (long-term hemodialysis, transfusion before 1992, injection drug use, HIV infection, persistently abnormal ALT)

Prevention Framework

• Primary Prevention (Prevention of Disease or Injury; eliminate/reduce risk factors):

  • Eat a nutritious diet, exercise, use seatbelts and helmets

  • Practice gun safety (safety locks, keep guns out of reach of children/teens)

  • Federal programs: immunizations, OSHA job safety laws, EPA environmental laws

  • Change risky behaviors (poor eating habits, tobacco use, not using condoms)

  • Build community resources (e.g., youth centers, Habitat for Humanity housing projects)

  • Aspirin prophylaxis for primary prevention of cardiovascular disease (CVD) in adults 40\to!59 years who have a \ge 10\% 10-year risk, and who are not at increased risk of bleeding; individual decision

• Secondary Prevention (Early Detection to Minimize Damage):

  • Screening tests: Pap smears, mammograms, CBC for anemia

  • Screening for depression (interview about mood)

  • Screening for STIs (testing and risk assessment)

  • Screening for alcohol use disorder (CAGE)

  • Testing for hepatitis C in adults with risk factors; anti-HCV testing for adults 18–79

• Tertiary Prevention (Reduce Impact/Rehabilitation/Support):

  • Support groups (AA, breast cancer support groups, HIV support groups)

  • Patient education (avoid drug interactions; wheelchair/medical equipment usage)

  • Rehabilitation: Cardiac rehab, PT, OT

  • Vocational rehabilitation programs (retrain workers after recovery)

USPSTF Recommendations (Selected Topics)

• Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer (April 2022)

  • Age 40\leq\text{age}<60 with \ge 10\% CVD risk: initiate low-dose aspirin for primary prevention, if life expectancy of at least 10\text{ years} and willing to take daily for at least 10\text{ years}, and not at increased bleeding risk

  • Age \ge 70 years: insufficient evidence about primary prevention

• Breast Cancer (January 2016)

  • Baseline mammogram at age 50 and every 2 years until age 74; update (as of Sept 2023 draft) to biennial screening for ages 40\text{ to }74

  • Insufficient evidence for routine mammography in those \ge 75\text{ years}

  • Does not apply to known high-risk (e.g., BRCA1/BRCA2); ACS recommends annual breast MRI + mammogram for highest risk starting around age 30

• Cervical Cancer (August 2018)

  • Note: recommendations do not apply to certain immunocompromised populations depending on circumstances

• Colorectal Cancer (May 2021)

  • Baseline: age 45\text{ to }75

  • Age 76–85: against routine screening; individualize

  • Age \ge 85: do not screen

  • Acceptable screening methods for average risk: colonoscopy every 10\text{ years}; flexible sigmoidoscopy or CT colonography every 5\text{ years}; high-sensitivity FOBT or FIT every year; stool DNA (SDNA) every 1\text{ or }3\text{ years} (positive requires colonoscopy)

• Lipid Disorders (November 2016)

  • Total lipid profile after 9\text{ hour} fast; universal lipid screening for adults 40\to!75

  • USPSTF recommends low- to moderate-dose statin for primary prevention when criteria are met:

  • Age 40\to!75; one or more CVD risk factors; calculated 10-year risk \ge 10\%

  • For age \ge 76, insufficient evidence to recommend

  • Benefit depends on absolute baseline risk

• Lung Cancer (March 2021)

  • Screen persons who smoke (≥20\text{ pack-years}) or who quit in the past 15\text{ years}

  • Annual LDCT for age 50\to!80 years

  • Discontinue if never smoked for 15 years or if health status/likelihood of curative surgery is low

• Ovarian Cancer (February 2018)

  • Grade D: routine screening not recommended

  • High-risk patients: refer for genetic risk evaluation and counseling

  • BRCA1/BRCA2-positive: elevated risk for breast, ovarian, prostate, pancreatic cancers, melanoma

• Prostate Cancer (May 2018)

  • Age 55\to!69: individualize PSA screening after discussing harms (false positives, biopsy risks) vs benefits

  • Age \ge 70: do not screen

• Skin Cancer Behavioral Counseling (March 2018)

  • Counsel to minimize UV exposure for ages 6\text{ months to }24 with fair skin

  • Education includes avoiding sun 10 a.m.–4 p.m., SPF \ge 15, protective clothing, wide-brim hats

• Skin Cancer Screening (June 2023)

  • USPSTF concludes evidence is insufficient to assess balance of benefits/harms of screening by visual skin examination in adults

• Other routine screens not recommended by USPSTF (examples): oral cancer, prostate cancer screening, testicular cancer in adolescents/men

Comprehensive USPTF Health Screening Recommendations (Selected Highlights)

• Abdominal Aortic Aneurysm (December 2019)

  • Baseline: men 65\to!75 years who have smoked; one-time ultrasound screening

• Breast Cancer (January 2016; 2023 draft update mentioned earlier)

  • Baseline screening begins around 50 (possible update to 40 in draft)

  • Biennial mammography until about 74; individualized after that

• Blood Pressure in Adults (April 2021)

  • Baseline: start screening at age 18+; confirm outside clinical setting before treatment

• Colon/Colorectal Cancer (May 2021)

  • Baseline: start at 45; continue to 75; recap of screening modalities as above

  • Age 76–85: individualize; Age >85: stop routine screening

• Depression (May 2016 / Depression in Adults January 2023)

  • Adolescents (12–18): screen for major depressive disorder

  • Adults: include pregnant and postpartum patients in screening

• Diabetes Mellitus Type 2 (August 2021)

  • baseline: screen adults with overweight/obesity and age between 35\text{ and }70; apply in primary care settings; consider younger ages with risk factors

• Hepatitis C Virus infection (March 2020)

  • baseline: age 18–79

• HIV Infection (June 2019)

  • baseline: age 15–65; screen; pregnant people: screen

• Latent Tuberculosis (May 2023)

  • baseline: asymptomatic adults at increased risk; screen

• Lung Cancer (March 2021) – reiterated

• Obesity in Adults (September 2018) and Obesity in children/adolescents (June 2017)

  • baseline: start at age 6–18; offer or refer for intensive behavioral interventions

• Sexually Transmitted Infections (August 2020)

  • baseline: start at onset of sexual activity; high-intensity counseling for high-risk groups

• Skin Cancer (April 2023)

  • baseline: insufficient evidence for routine screening; individualize

• Osteoporosis (June 2018)

  • baseline: start at 65 years or older; may start earlier with fracture risk comparable to a 65-year-old White woman

• Pancreatic Cancer (August 2019)

  • baseline: asymptomatic adults; do not screen

• Syphilis Infection (September 2022)

  • baseline: asymptomatic adults/adolescents; screen those at increased risk; pregnant people: early screening

Risk Factors (Key Cancers and STIs)

• Breast Cancer — major risk factors:

  • Age 50+, previous history of breast cancer, BRCA1/BRCA2 mutation, high-dose chest radiation at a young age, two or more first-degree relatives with breast cancer, early menarche, late menopause, nulliparity, obesity

• Cervical Cancer — risk factors:

  • Multiple sex partners (>4 lifetime), younger age at first sex, immunosuppression and smoking

• Colorectal Cancer — risk factors:

  • Familial polyposis; first-degree relative diagnosed with colon cancer <60; chronic inflammatory bowel disease (ulcerative colitis, Crohn’s)

• Prostate Cancer — risk factors:

  • Age 50+, genetic predisposition, first-degree relative with prostate cancer

• Sexually Transmitted Infections — risk factors:

  • Unprotected sex, multiple or anonymous partners, early age of onset, new partners (within <3\text{ months})

• General STI risk factors (overview): history of STI, homelessness, etc.

Vaccines and Immunizations: Schedules, Facts, and Safety

• Hepatitis B vaccine (HepB)

  • Schedule: 3 doses at 0,1,6\text{ months}; first dose at birth (monovalent HepB)

  • Catch-up: if series not completed, do not restart; complete the 3-dose series

  • If only one dose given: give the second dose; catch up until three-dose series completed

  • CDC 2023 Immunization Recommendations for Adults/Teens (age 19+): COVID-19—two or three primary series + booster; Hepatitis B—2–4 doses depending on regimen; Td/Tdap schedule; influenza annually; alternative (egg-free) vaccines for influenza available; MMR, Varicella, Shingles, Pneumococcal, etc.

• Influenza vaccines (seasonal)

  • Start end of October; vaccination should continue as long as viruses circulate (often into January or later)

  • All healthcare personnel should be vaccinated annually

  • Egg allergy: if hives only, influenza vaccine can be given; those with serious egg reactions should be in a setting capable of managing severe allergy

  • Egg-based vaccines: options include inactivated (IIV) and live attenuated (LAIV) vaccines; recombinant vaccines (cell-based) available for egg-free options

  • Contraindications for all influenza vaccines: infants \leq 6\text{ months}; severe, life-threatening allergies to vaccine components unrelated to egg

  • LAIV contraindications: pregnancy; chronic disease (e.g., asthma, COPD, renal disease, diabetes, immunosuppression); children on aspirin 2–17 years; children 2–4 with asthma/wheeze history

  • Egg allergy considerations: vaccines exist that are egg-free; some vaccines require caution with Guillain–Barré syndrome history

  • Time to effectiveness: about 2\text{ weeks}; immunity lasts around 6\text{ months}; early vaccination (July/August) may yield suboptimal protection later in season; aim for vaccination by October

• Pneumococcal vaccination

  • PPSV23 (Pneumovax): 1 dose for adults 65+ or those at high risk (age 2–64 with risk factors); if vaccinated before 65, a booster at 65+ is recommended at least 5\text{ years} after prior dose; PPSV23 effectiveness ~ 50\%$ to 85\%

  • PCV13 (Prevnar): high-risk adults receive a four-dose series; PCV13 recommended for adults 19+ with certain conditions; for those 65+, PCV13 should be given at least 1\text{ year} after PPSV23

  • Highest risk groups include chronic diseases, CSF leaks, asplenia, immunocompromised, cancer, renal disease, etc.

• Shingles (Herpes Zoster) Vaccination

  • Shingrix (Recombinant Zoster Vaccine): for adults 50+; two injections 2 to 6 months apart

  • ACIP recommends Shingrix for those previously given Zostavax; can receive even after shingles or without known history of chickenpox

  • Two-dose series; if second dose delayed >6 months after first, do not restart—give second dose

  • Risk factors: age 60+; immunocompromise; leukemia/lymphoma; other factors; contraindications include active shingles, pregnancy/breastfeeding, negative varicella zoster titer (then give varicella vaccine instead)

  • Efficacy: Shingrix ~ 90\% effective against shingles

• Tetanus Vaccines (Tdap and Td)

  • Td/Tdap: booster every 10\text{ years} for lifetime; Tdap can substitute for one Td booster once in lifetime (11–12 years
    a ge)

  • For dirty wounds: last dose >5 years ago, give tetanus booster; if wound is contaminated and not up-to-date, give TIG (tetanus immune globulin)

• Varicella (Chickenpox) Vaccine

  • Varicella live attenuated vaccine (Varivax): two-dose schedule; first dose at 12\text{–}15\text{ months}; second dose at 4\–6\text{ years}; adolescents and adults needing two doses spaced 4–8 weeks apart

  • Do not vaccinate pregnant individuals within 1\text{ month} of vaccination

  • ProQuad (MMRV) combines measles, mumps, rubella, and varicella for those 12\text{ years} or younger

  • Post-exposure prophylaxis: ideally within 72\text{ hours}; may be given up to 5\text{ days} after exposure for previously unvaccinated healthy individuals

  • Reactions: mild rash; contagious small varicella rashes; avoid immunocompromised

  • Acceptable proof of varicella immunity: two vaccine doses; documented varicella or shingles by clinician; positive Varicella IgG; birth in the U.S. before 1980; routine post-two-dose testing not recommended

• MMR and MMRV Precautions

  • MMR/Measles, Mumps, Rubella: proof of immunity required for healthcare personnel; if not vaccinated, two doses at least 28\text{ days} apart

  • Varicella immunity proof required for healthcare workers; two doses or documented immunity

• Hepatitis B Immunization (reiterated)

  • If incomplete: complete the series; do not restart if incomplete

Special Considerations for Healthcare Personnel Vaccination

• All healthcare workers should receive influenza vaccination annually.

• Tdap: one-time dose for all healthcare workers who have not received it previously; pregnant healthcare workers should receive a Tdap during each pregnancy (preferably between 27^{\text{o}} and 36^{\text{o}} weeks gestation)

• MMR: proof of immunity required (born before 1957 or documented immunity)

• Varicella: proof of immunity required (positive titer or two doses or prior disease documented by clinician)

• Hepatitis B: complete the series if incomplete; check anti-HBV after completion

• BCG (Bacillus Calmette–Guerin) vaccination availability: TB vaccine used in some settings; can cause a false-positive TB skin test; TB blood tests (IGRAs) are preferred if history of BCG vaccination

Tuberculosis (TB) Testing and Latent TB Infection (LTBI)

• If TB skin test is positive or if TB blood test is positive:

  • Evaluate for signs/symptoms of active TB; order chest X-ray; assess for latent or active TB infection

  • Four treatment regimens for LTBI (as of April 2019); refer to TB guidelines for specifics; consider shorter regimens to improve completion rates

  • Seek TB specialist consultation if drug-resistant TB suspected

• Pearls:

  • Without treatment, about 1\text{ in }10 with LTBI will develop TB disease

  • Antibodies to influenza take about 2\text{ weeks} to develop after vaccination; flu vaccine protection lasts at least 6\text{ months}

  • For adults >= 65, higher-dose vaccines (e.g., Fluad, Fluzone High-Dose) can be more effective

  • Baloxavir marboxil (Xofluza) is a single-dose antiviral for acute uncomplicated influenza within 2\text{ days} of illness onset in people ≥12 years; used when appropriate

  • Remind patients to get the influenza vaccine by the end of October; earlier vaccination is recommended but vaccination can continue into later months as season persists

Vaccine Safety, Contraindications, and Practical Notes

• Safety Issues:

  • Severe reactions after eggs: vaccine should be given in a setting capable of handling anaphylaxis

  • 2020 CDC guidance: patients with only hives to egg can usually receive the flu vaccine; observation time may be shortened

  • Egg-allergic individuals may receive egg-based vaccines with precautions; recombinant or cell-based vaccines are options

  • Guillain–Barré syndrome within 6 weeks of a previous influenza vaccine: use caution with pertussis component or avoid

• Vaccine Facts (Key Takeaways):

  • Flu vaccine takes ~2 weeks to become effective; protection lasts ~6 months; early vaccination may wane by season end, particularly in older adults

  • For those 65+ years, high-dose or adjuvanted vaccines may be preferable for better protection

  • Shingrix efficacy ~ 90\%; two doses required; provide even if previously had shingles

  • Varicella vaccine provides immunity in two doses; post-exposure prophylaxis works best if given within 72 hours; MMRV combines measles, mumps, rubella, and varicella for eligible age groups

• Notes on contraindications:

  • Vaccines generally contraindicated in pregnancy for some live vaccines (e.g., live attenuated varicella, MMR) unless guidelines permit

  • Immunocompromised status and ongoing cancer therapy may alter vaccine recommendations; consult guidelines

  • BCG vaccination can complicate TB skin testing; blood-based TB tests (IGRAs) are preferred for those with prior BCG

Follow-Up and Programmatic Considerations

• The National Vaccine Injury Compensation Program (VICP) exists to compensate certain vaccine injuries at a federal level; awareness for patients receiving vaccines

• Healthcare education pearls:

  • Encourage completion of vaccine series; do not restart incomplete multi-dose series

  • Ensure age-appropriate immunizations for all ages, including catch-up schedules for adults and adolescents

  • Encourage vaccination during pregnancy for protection of newborns (e.g., Tdap during pregnancy)

  • Emphasize the importance of staying up to date in older adults with higher-dose vaccines where appropriate

Quick Reference Facts and Numbers (Summary)

• Life expectancy (US, 2021): 76.4\text{ years} overall; 73.5\text{ years} male; 79.3\text{ years} female

• Leading causes of death (all ages): 22\% female heart disease, 24\% male heart disease; cancer 21\% female, 22\%$$ male

• Major cancer deaths by site: Lung and bronchus, Colon and rectum, Pancreas

• Screening and prevention principles emphasize balancing benefits with risks, evidence quality, and patient preferences across different ages and risk profiles

• Vaccination strategies emphasize tailored schedules, catch-up strategies, and safety considerations for special populations (pregnant people, immunocompromised, elderly, and healthcare workers)

These notes consolidate the key ideas, numbers, guidelines, and practical implications from the transcript content. They are organized to serve as a study-ready reference that mirrors the breadth of topics covered, including mortality statistics, cancer data, preventive services, screening recommendations, and vaccination guidance.