national screening guidelines for priority non

NATIONAL SCREENING GUIDELINES FOR PRIORITY NON-COMMUNICABLE DISEASES (NCDs)

IN PRIMARY HEALTH CARE

ISSUED: JUNE 2020

2

MINISTRY OF HEALTH AND WELLNESS

NATIONAL SCREENING GUIDELINES FOR PRIORITY NON-COMMUNICABLE DISEASES (NCDs)

IN PRIMARY HEALTH CARE

JUNE 2020

Approved by:

___________________________________________ Dr Jacquiline Bisasor McKenzie

Chief Medical Officer

__________________________________ Dr Simone Spence

Director, Health Promotion and Protection Branch

NATIONAL SCREENING GUIDELINES FOR PRIORITY NON-COMMUNICABLE DISEASES (NCDs) IN PRIMARY HEALTH CARE

3

INTRODUCTION TO SCREENING GUIDELINE DOCUMENT

This guideline document is organized into 8 chapters. The introduction to the screening

guidelines for the priority non-communicable diseases (NCDs) gives an overview of the

priority NCDs included in this document. The status of each NCD is provided and the

approach taken in developing the guidelines is articulated. Chapters 2 to 8 are the

guidelines for the 7 priority NCDs included: Chapter 1: Introduction to the screening

guidelines; Chapter 2: Hypertension and Cardiovascular Disease; Chapter 3: Depression;

Chapter 4: Diabetes Mellitus Type 2; Chapter 5: Breast Cancer; Chapter 6: Cervical

Cancer; Chapter 7: Colorectal Cancer; and Chapter 8: Prostate Cancer.


3

INTRODUCTION TO SCREENING GUIDELINE DOCUMENT

This guideline document is organized into 8 chapters. The introduction to the screening

guidelines for the priority non-communicable diseases (NCDs) gives an overview of the

priority NCDs included in this document. The status of each NCD is provided and the

approach taken in developing the guidelines is articulated. Chapters 2 to 8 are the

guidelines for the 7 priority NCDs included: Chapter 1: Introduction to the screening

guidelines; Chapter 2: Hypertension and Cardiovascular Disease; Chapter 3: Depression;

Chapter 4: Diabetes Mellitus Type 2; Chapter 5: Breast Cancer; Chapter 6: Cervical

Cancer; Chapter 7: Colorectal Cancer; and Chapter 8: Prostate Cancer.


4

ACKNOWLEDGEMENT In compiling this document, the primary source of information was the output drafted by

Dr. Celia Poon-King. Dr. King’s document emanated from a wide consultative process

with medical and other health care practitioners working across the four (4) Regional

Health Authorities. These consultations involved specialist clinicians in public health and

in areas of non-communicable diseases and cancers.

The consultants also wish to acknowledge the contribution of the following specialists who

provided further clarity in the refinement of these guidelines. They are as follows:

Dr. Gillian Lowe - De La Haye – Consultant Psychiatrist

Dr. Earl Wright – Consultant Psychiatrist

Dr. Patrick Roberts – Consultant General Surgeon, Surgical Oncologist &

Hepatobiliary Surgeon

Dr. Matthew Taylor – Consultant Obstetrician/Gynaecologist, Gynaecological

Oncologist

Dr. Ian Bambury – Consultant Obstetrician/Gynaecologist, Gynaecological

Oncologist

Dr. Kevan Smith – Consultant General Surgeon & Colorectal Surgeon

Dr. Gareth Reid – Consultant Urologist

The work to develop these guidelines was supported by:

Dr. Pharez George, Consultant Public Health, Infectious Disease Specialist

Dr. Ertenisa Hamilton, Consultant Public Health, Primary Health Care Specialist

Dr. Camelia Clarke, Public Health Specialist

Dr. Hamlet Nation, Consultant Public Health Physician (Lead Consultant)

NATIONAL SCREENING GUIDELINES FOR PRIORITY NON-COMMUNICABLE DISEASES (NCDs) IN PRIMARY HEALTH CARE TO PROMOTE EARLY DETECTION

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TABLE OF CONTENTS

INTRODUCTION TO SCREENING GUIDELINE DOCUMENT .............................................. 3 ACKNOWLEDGEMENT ......................................................................................................... 4 GLOSSARY ........................................................................................................................... 7 ABBREVIATIONS .................................................................................................................. 9 LIST OF FIGURES ................................................................................................................10 PREFACE .............................................................................................................................11

Chapter 1 INTRODUCTION TO SCREENING GUIDELINES FOR PRIORITY NCDs . 1-1

1. Introduction ............................................................................................................... 1-1

2. Status of NCDs in Jamaica ....................................................................................... 1-2

3. Purpose .................................................................................................................... 1-5

4. Target Audience ....................................................................................................... 1-5

5. How to Use the Manual ............................................................................................. 1-6

Chapter 2 SCREENING GUIDELINES FOR HYPERTENSION & CVD ....................... 2-1

2.1 Risk Groups for the Screening of Hypertension and Cardiovascular Disease (CVD) .... 2-1

2.2 Childhood and Adolescence ......................................................................................... 2-4

2.3 Adulthood ..................................................................................................................... 2-5

2.4 Adult Female during Pregnancy .................................................................................... 2-7

2.5 Late Adulthood (Elderly) ............................................................................................... 2-9

Chapter 3 SCREENING GUIDELINES ........................................ 3-1FOR DEPRESSION

3.1 Risk Groups and Special Considerations for Depression Screening ............................. 3-1

3.2 Adolescence ................................................................................................................. 3-3

3.3 Adulthood ..................................................................................................................... 3-4

3.4 Pregnant / Post-Partum Females .................................................................................. 3-5

3.5 Late Adulthood (Elderly) ............................................................................................... 3-6

Chapter 4 SCREENING GUIDELINES FOR DIABETES MELLITUS TYPE 2 .............. 4-1

4.1 Risk Groups and Special Considerations for the Screening of Diabetes Mellitus (DM) Type 2 ................................................................................................................................ 4-1

4.2 Childhood & Adolescence ............................................................................................. 4-4

4.3 Adulthood and Late Adulthood ...................................................................................... 4-5

4.4 Adult Female during Pregnancy .................................................................................... 4-7

Chapter 5 SCREENING GUIDELINES FOR BREAST CANCER ................................. 5-1

5.1 Risk Groups and Special Considerations in Screening for Breast Cancer ..................... 5-1

5.2 Adolescence to 39 years ............................................................................................... 5-3

5.3 Adult and Older Female (Age 40-69 years) ................................................................... 5-4


6

5.4 Late Adulthood (Older Female ≥70 years) .................................................................... 5-6

Chapter 6 SCREENING GUIDELINE FOR CERVICAL CANCER ............................... 6-1

6.1 Risk Groups and Special Considerations in Screening for Cervical Cancer .................. 6-1

6.2 Childhood & Adolescence ............................................................................................. 6-3

6.3 Adult Female (20-29 years) .......................................................................................... 6-3

6.4 Adult Female (30-49 years) .......................................................................................... 6-4

6.5 Adult Female (Menopausal & Immediate Post-Menopausal 50-64 years) ..................... 6-5

6.6 Adult Female (65 years and older) ................................................................................ 6-6

Chapter 7 SCREENING GUIDELINE FOR COLORECTAL CANCER ......................... 7-1

7.1 Risk Groups and Special Considerations in Screening for Colorectal Cancer ............... 7-1

7.2 Adolescence ................................................................................................................. 7-3

7.3 Adulthood (age 20-44 years) ........................................................................................ 7-3

7.4 Adulthood (age 45- 74 years)........................................................................................ 7-4

7.5 Adulthood (age 75 years or older) ................................................................................. 7-6

Chapter 8 SCREENING GUIDELINE FOR PROSTATE CANCER .............................. 8-1

8.1 Risk Groups and Special Considerations in Screening for Prostate Cancer .................. 8-1

8.2 Adolescence ................................................................................................................. 8-3

8.3 Adulthood (age 20-39 years) ........................................................................................ 8-3

8.4 Adulthood (age 40- 69 years)........................................................................................ 8-3

8.5 Adulthood (age 70 years or older) ................................................................................. 8-5

REFERENCES.............................................................................................................R-1

APPENDICES ..............................................................................................................A-1

APPENDIX A1: Screening of Blood Pressure Values Requiring Further Evaluation in Children& Adolescents .....................................................................................................................A-1

APPENDIX A2: Body Mass Index for Age (Z-score)............................................................A-1

APPENDIX A3: World Health Organization Cardiovascular Disease Risk Prediction andAssessment ........................................................................................................................A-3

A3.1 CV Risk Prediction Charts - Caribbean ............................................ A-3

Comprehensive Clinical Assessment for CV Risk ...........................A-6

APPENDIX A4: Summary Full Medical Profile - Major Depression......................................A-7

APPENDIX A5: 6-Item Kutcher Adolescent Depression Scale: KADS-6..............................A-9

APPENDIX A6: Patient Health Questionnaire 9-Items (PHQ-9)......................................... A-11

AA3.2

NATIONAL SCREENING GUIDELINES FOR PRIORITY NON-COMMUNICABLE DISEASES (NCDs) IN PRIMARY HEALTH CARE TO PROMOTE EARLY DETECTION

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GLOSSARY

BRCA 1/2 refer to human genes that produce tumour

suppressor proteins that help repair damaged

DNA

FIT is faecal immunochemical test, a newer faecal

occult blood test that uses a specific antibody for

human haemoglobin

FIT-DNA is a combination of the faecal immunochemical

test and a second test that looks for cancerous

DNA in an individual’s stool. It is done every 1-3

years to check for colon cancer

Follow up refers to the action indicated when an abnormal

screening test result is received. The person is

referred for further care and then returns to

primary care for continued screening. It addresses

the return to or continued screening

Full medical profile - MD is Full Medical Profile for Major Depression, as

described in Protocol for the Management of

Common Mental Disorders (2013): Major

Depression. See Appendix 4 for the summary

Primary care is defined as the first contact in accessible,

continued, comprehensive and coordinated care.

First-contact care is accessible at the time of need

Primary health care as defined by WHO includes three components:

“(1) meeting people’s health needs through

comprehensive care throughout the life course, (2)

systematically addressing the broader

determinants of health and (3) empowering


8

individuals, families and communities to optimize

their health (WHO web page)”

Referral describes the actions to be taken when further

action is required at a different point of care in the

health care system from “where” the initial

screening was performed

Screening is "the presumptive identification of unrecognized

disease or defect by the application of tests,

examinations or other procedures which can be

applied rapidly”


9

ABBREVIATIONS

BP Blood Pressure

BMI Body Mass Index

CBE Clinical Breast Examination

CVD Cardiovascular Disease

DRE Digital Rectal Examination

FBG Fasting Blood Glucose

FIT Faecal Immunochemical Test

FPG Fasting Plasma Glucose

GDM Gestational Diabetes Mellitus

gFOBT Guaiac – Faecal Occult Blood Test

HPV Human Papillomavirus

hrHPV high risk Human Papillomavirus

KADS Kutcher Adolescent Depression Scale

M&E Monitoring and Evaluation

NCDs Non-communicable diseases

NGO Non-Governmental Organisation

NPHL National Public Health Laboratory

OGTT Oral Glucose Tolerance Test

PAHO Pan American Health Organisation

Pap Papanicolaou

PHC Primary Health Care

PHQ Patient Health Questionnaire

PPP Public Private Partnership

PSA Prostate Specific Antigen

STI Sexually Transmitted Infection

SBE Breast Self-Examination

VIA Visual Inspection with Acetic Acid Test

WHO World Health Organisation


10

LIST OF FIGURES Figure 1: Algorithm for Screening, Referral and Follow Up in Children and Adolescents at

Average and High Risk for High Blood Pressure ................................................................... 2-12

Figure 2: Algorithm, Screening, Referral and Follow Up in Adults at Average and High Risk for

High Blood Pressure and CVD Risk ...................................................................................... 2-13

Figure 3: Algorithm for Screening, Referral and Follow up in Pregnant Women at Average and

High Risk for High Blood Pressure and CVD Risk ................................................................. 2-14

Figure 4: Algorithm for Screening, Referral and Follow Up in the Elderly at Average and High

Risk for High Blood Pressure and CVD Risk ......................................................................... 2-15

Figure 7: Algorithm, for Screening Referral and Follow-up in Children and Adolescents at High

Risk for Diabetes Mellitus Type 2 ............................................................................................ 4-9

Figure 8: Algorithms for Screening Referral and Follow-up in Adults at Average Risk for Type 2

Diabetes Mellitus ................................................................................................................... 4-10

Figure 9: Algorithms for Screening Referral and Follow-Up in Adults at High Risk for Diabetes

Mellitus Type 2 ...................................................................................................................... 4-11

Figure 10: Algorithm for Screening Referral and Follow Up in Women at Average Risk for

Diabetes in Pregnancy .......................................................................................................... 4-12

Figure 11: Algorithm for Screening Referral and Follow Up in Women at High Risk for Diabetes

in Pregnancy ......................................................................................................................... 4-13

Figure 12: Algorithm for Screening, Referral and Follow Up in Women at Average Risk for

Breast Cancer ......................................................................................................................... 5-7

Figure 13: Algorithm for Screening, Referral and Follow up in Women at High Risk for Breast

Cancer .................................................................................................................................... 5-8

Figure 14: Algorithm for Screening, Referral and Follow of Women at Average Risk for Cervical

Cancer .................................................................................................................................... 6-7

Figure 15: Algorithm for Screening, Referral and Follow Up in Women at High Risk for Cervical

Cancer .................................................................................................................................... 6-8

Figure 16: Recommended Primary HPV Screen and Treat Algorithm ..................................... 6-8

Figure 17: Algorithm for the Screening and Follow Up of Adults at Average or High Risk for

Colorectal Cancer ................................................................................................................... 7-7

Figure 18: Algorithm for Screening Referral and Follow Up of Men at Average and High Risk of

Prostate Cancer ...................................................................................................................... 8-7


11

PREFACE

Countries across the world continue to face the large financial burden of providing care

for persons affected by Non-Communicable Diseases (NCDs), the burden of which has

increased significantly over the last decade and is predicted to continue this trend for the

next two decades or more.

Reducing the burden of NCDs is a colossal task that will require not only

public health interventions but commitment from governments to have funding available

to adequately address this public health issue, as well as the participation of non-health

sectors and non-governmental partners. The Public Health machinery has a pivotal role

to play as the main vehicle to drive the changes that are necessary.

These guidelines have been developed and are based on some core concepts which

include:

The Essential Public Health Functions defined as “diagnosing and investigating

health problems and health hazards in the community, in order to manage as well as

prevent their spread and lessen their impact on the population (1).”

Screening, the presumptive identification of unrecognized disease in an apparently

healthy, asymptomatic population by means of tests, examinations or other

procedures that are readily applied. It plays a key role in protecting the overall health

of the population and advancing public health goals (2).

The Life Course Approach which emphasizes a temporal and social perspective,

looking back across an individual’s or a cohort’s life experiences or across generations

for clues to current patterns of health and disease, whilst recognizing that both past

and present experiences are shaped by the wider social, economic and cultural

context. The life course approach is used to study the physical and social hazards


12

during gestation, childhood, adolescence, young adulthood, and midlife that affect

chronic disease risk and health outcomes in later life. It aims to identify the underlying

biological, behavioural and psychosocial processes that operate across the life span

(3).

Continuum of care conceptually involves an integrated system of care that guides

and tracks patients over time through a comprehensive array of health services

spanning all levels of intensity of care. In patients with a disease, this covers all phases

of illness from diagnosis to the end of life (4).

These core concepts, functions and framework form the foundation for the creation of the

Ministry of Health and Wellness (MOHW) NCD Screening Guidelines outlined in the

subsequent chapters of this document. These guidelines are a user-friendly tool that will

assist health care providers in improving the quality of services that are available and

recommended for the citizens of Jamaica. The MOHW anticipates that with full

implementation there will be tangible results that translate into a healthy population that

can effectively contribute to the development of Jamaica.

SUBJECT: SCREENING GUIDELINES FOR PRIORITY NCDs PAGE1-1 Chapter 1 INTRODUCTION TO SCREENING GUIDELINES FOR PRIORITY NCDs

DATE ISSUED: ( ) Revised ( ) New

1. Introduction Non-Communicable Diseases (NCDs) have been identified as a priority for action at the

international, regional and national levels. A key strategy for the prevention and control

of NCDs being employed by the Ministry of Health and Wellness (MOHW), Jamaica, is

the early detection and diagnosis of these diseases. This strategy has been employed

because there is well-established evidence that early detection (screening and early

diagnosis) of cardiovascular disease (CVD) (e.g. hypertension), diabetes, depression and

breast, cervical and colorectal cancers can reduce premature mortality due to these

NCDs.

In order to drive this strategy of early detection and diagnosis, the MOHW has developed

through wide stakeholder consultations, the National Screening Guidelines for the

Primary Health Care Screening of certain priority NCDs namely, hypertension and

cardiovascular disease, diabetes, breast cancer, cervical cancer, colorectal cancer,

prostate cancer and depression. The guidelines were developed utilizing two main

approaches: i) the life course approach and ii) the continuum of care. The life course

approach aims to identify the underlying processes that operate across the life span of

the individual. The continuum of care tactic involves an integrated system of care which

links and tracks beneficiaries to the various levels of the health care delivery system in

Jamaica.

Screening offers the most cost-effective opportunity for the health care system to identify

disease at a stage when treatment is more effective and long-term complications can be

delayed or avoided. These screening guidelines establish evidence-based approaches

which have been adapted to accommodate the local realities and resources of Jamaica.

The guidelines also provide tools for monitoring of their implementation across the

primary health care infrastructure of the four (4) Regional Health Authorities.

SUBJECT: SCREENING GUIDELINES FOR PRIORITY NCDs PAGE1-1 Chapter 1 INTRODUCTION TO SCREENING GUIDELINES FOR PRIORITY NCDs

DATE ISSUED: ( ) Revised ( ) New

1. Introduction Non-Communicable Diseases (NCDs) have been identified as a priority for action at the

international, regional and national levels. A key strategy for the prevention and control

of NCDs being employed by the Ministry of Health and Wellness (MOHW), Jamaica, is

the early detection and diagnosis of these diseases. This strategy has been employed

because there is well-established evidence that early detection (screening and early

diagnosis) of cardiovascular disease (CVD) (e.g. hypertension), diabetes, depression and

breast, cervical and colorectal cancers can reduce premature mortality due to these

NCDs.

In order to drive this strategy of early detection and diagnosis, the MOHW has developed

through wide stakeholder consultations, the National Screening Guidelines for the

Primary Health Care Screening of certain priority NCDs namely, hypertension and

cardiovascular disease, diabetes, breast cancer, cervical cancer, colorectal cancer,

prostate cancer and depression. The guidelines were developed utilizing two main

approaches: i) the life course approach and ii) the continuum of care. The life course

approach aims to identify the underlying processes that operate across the life span of

the individual. The continuum of care tactic involves an integrated system of care which

links and tracks beneficiaries to the various levels of the health care delivery system in

Jamaica.

Screening offers the most cost-effective opportunity for the health care system to identify

disease at a stage when treatment is more effective and long-term complications can be

delayed or avoided. These screening guidelines establish evidence-based approaches

which have been adapted to accommodate the local realities and resources of Jamaica.

The guidelines also provide tools for monitoring of their implementation across the

primary health care infrastructure of the four (4) Regional Health Authorities.

CHAPTER 1: Introduction to screening guidelines for priority NCDs

Date Issued: ( ) Revised ( ) New

Page 1-2

2. Status of NCDs in Jamaica

Non-Communicable Diseases account for the top five (5) leading causes of death in

Jamaica. In 2016, three (3) main NCD-groups accounted for 12,066 or 65.7% of all deaths

(18,373) in persons 5 years and older (cardiovascular disease 6189 or 33.7%; cancer

3538 or 19.3%; and diabetes 2339 or 12.7%) (5).

Metabolic risk factors for NCDs are also high and continue to increase in both adults and

adolescents. In relation to mental health and well-being, students 13-15 years old who

attempted suicide decreased from 2008 to 2016 but the rates are still considered high (6).

Many Jamaicans are also unaware that they have an NCD until they are diagnosed in

advanced stages of the diseases with severe disability or die prematurely from their

condition. This was evidenced in findings which indicate that 4 out of 10 persons with

raised blood pressure and diabetes were unaware of their condition (6). More women

than men are aware of their disease status, and are obese, whilst more men than women

smoke and abuse alcohol. The occurrence of NCDs also increases with age and NCDs

develop at different stages of the life course.

Hypertension Hypertension is one of the major health issues facing Jamaica as defined in the

Jamaica Health and Lifestyle Survey III (2016-2017). The results of this survey

indicated that 57.6% of the over 15 years population was hypertensive; the

prevalence was as follows among the sexes: 58.3% of all males and 57.6% of all

females were hypertensive (6). The data further suggested that this disease was

more prevalent among the rural population at 35.2%, than the urban population at

33%.



Page 1-3

Depression The prevalence of depression in Jamaica in 2008 was 20.3% or 1 in 5 persons (6),

while in 2016, the prevalence was 14.3% or 1 in 7 persons (6). In the general

population almost twice as many females, 18.5%, were depressed compared to

men, 9.9% (6).

Data from the 2008 Jamaica Health and Lifestyle survey shows that the rate of

depression in persons with chronic illnesses was between 20-30%. Among these

persons with chronic illnesses, the rate was the same for persons with a history of

diabetes, hypertension, cancers, asthma and high cholesterol (25%), lower among

persons with obesity (20%) and higher in persons with a history of heart attack and

stroke (30%) (6).

Suicide attempts and ideation are proxies for depression and other mental health

disorders. In 2008, 2.0% of the female population and 1.7% of males reported

suicidal ideation (6). Suicide attempts in teenagers 13-15 years old is considered

to be high even though there had been some decrease from 22% in 2010, to 18.3

% in 2016 (8) (9).

Diabetes Mellitus

It is estimated that 14% of all Jamaicans are currently living with Diabetes Mellitus

(DM). In 2018 it was estimated that 12% of Jamaicans had pre-diabetes with a

higher prevalence among women (13.3%) than men (10.7%) putting them at higher

risk of developing DM. In 2018 DM represented the 4th (14%) leading cause of

mortality among Jamaicans and 25% of Jamaicans that have DM may not know

their status (6). This narrative focuses mainly on the preventability of type 2 DM as

an avenue for positively affecting this indicator, however, diabetes has implications

for health over the life course and proper screening and management of DM is

crucial for improving health outcomes (6)(10).



Page 1-4

Breast Cancer

In Jamaica, there were 974 new cases of breast cancer in 2018. This was 13.3%

(1 in 8) of all new cancer cases and 25.3% (1 in 4) of new cancer cases in women.

Although screening for breast cancer is undertaken in Jamaica, there is presently

no national mammography-based screening programme. A national cancer

registry was launched in 2018 (40). This should be used to monitor the incidence

of breast cancer in Jamaica over time as the screening guideline is implemented

(11)(12).

Cervical Cancer

For cervical cancer, there were 486 new cases reported in Jamaica in 2018. This

was 6.6% (1 in 15) of all new cancer cases and 12.6% (1 in 8) of new cancer cases

in women. Mortality from cervical cancer in women for all ages has fluctuated over

the 30-year period, 1980 to 2011. In 2011, the all age mortality rate was

15.1/100,000 and the age-standardised mortality rate was 14.9/100,000. Deaths

increased consistently with age, from age 30 years old. Over the time period 1980

to 2011, the number of deaths in the age group from 40 to 75 years old increased

but the mortality rates decreased in all age groups (11)(12).

Colorectal Cancer

There were 953 new cases of colorectal cancer in 2018. This was 13% (1 in 8) of

all new cancer cases (13). From 1980 to 2011, the number of deaths in the age

range 45 to 75 years increased and the mortality rates also increased in all age

groups in males and females. The percentage of deaths from colorectal cancer is

highest in females and males aged 60-64 years old. Colorectal cancer represents

the 5th leading cause of death among all cancers, the 3rd leading cause of death

among men and the 2nd leading cause of death among women (11) (12).



Page 1-5

Prostate Cancer

In Jamaica, there were 1,309 new cases of prostate cancer in 2018. This was

17.8% (1 in 6) of all new cancer cases and 37.5% (2 in 5) of new cases in men.

The highest number of prostate cancer deaths occurred in men between the ages

of 55 to 85 years of age (13). Over the period 1980 to 2011, the number of deaths

in persons age 50 years old and greater, has shown a steady increase while the

mortality rates have also been increasing in all the older age groups (11) (12).

3. Purpose The main purpose of this guideline is to provide the technical guidance for the early

detection, referral and follow-up of priority NCDs – breast, cervical, colorectal, and

prostate cancers; depression, diabetes mellitus type 2, and high blood pressure – at the

primary health care (PHC) level. The long-term goal of the guidelines is to contribute to

reduction in premature mortality due to NCDs by a third by 2030, in keeping with

Sustainable Development Goal 3.4.

4. Target Audience These guidelines are intended primarily for members of the primary health care team.

These include doctors, family nurse practitioners, public health nurses, registered nurses,

midwives, contact investigators, community health aides, health promotion/education

officers and other professionals in the health sector who have responsibility for the

delivery of screening and early detection services for NCDs at the primary health care

level. Other individuals working in the management of NCD screening programmes

including programme managers at the parish, regional and national levels will find the

guidelines useful for programme management, which is inclusive of resource allocation

and monitoring and evaluation of the performance of programmes for the prevention and

control of NCDs.



Page 1-6

5. How to Use the Manual

This manual is the summarized version of a wider set of documents developed to guide

the health worker and health facility team in both the public and private sector on

screening for NCDs. It should be available at every primary care facility and health care

personnel should familiarize themselves with the content and apply this to patient

encounters. It should be strategically located so it can function as a quick reference in

instances where there are challenges in the management of any case that falls within the

subject areas covered.

The manual provides information on risk classification and special considerations for the

NCDs that have been included.

For reference and use during the patient encounter the user will be required to:

a) identify the patient’s age and stage along the life course

b) classify the patient based on risk (average or high risk) for the NCD being reviewed

c) identify the recommended screening test for the patient, appropriate to their life

course stage, age and risk classification

Each table also contains useful comments that will provide further clarity on the

recommended screening approach as well as special considerations that should be

taken. These guidelines include useful appendices that provide additional tools that may

be required for assessment of the patient. An algorithm for screening and follow-up of

each of the priority NCDs is included as a guide at the end of each chapter. The algorithm

is to be utilized as a quick tool to recall the screening recommendations explained in the

chapter.



Page 1-7

This manual should not be read in isolation of other documents and guidance developed by the Ministry of Health and Wellness for the management of NCDs. The table below represents a key for locations where the interventions for the selected NCDs should be addressed.

Definitions for target groups for intervention throughout the life course are provided below:

Children: This group refers to individuals 0-9 years of age.

Adolescence: This group refers to individuals aged 10 years to 19 years.

Adulthood: This group refers to individuals 20 years to 59 years of age.

The Elderly (Late Adulthood): This group refers to adults who are 60 years of

age or older.

Pregnant & Post-Partum: This group refers to females who are pregnant (all

stages of pregnancy from conception to delivery) and up to 6 weeks post-delivery.

In some priority NCDs there will be reference to other subgroups based on the evidence

surrounding the appropriate starting point for the initiation of screening.

Terms Meaning

Level 1 Speaks to Community and District Health Centres

Level 2 Speaks to Comprehensive Health Centres

Community The community can refer to the household or any institution (church, school, mosque) or organization (youth clubs, sport clubs, elderly clubs) where outreach activities are carried out

Yes This is an indication that the intervention (is recommended) at this level

N/A This is an indication that the intervention (is not recommended) at the level

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eigh

t, m

ale

sex,

eth

nici

ty, a

nd a

fam

ily h

isto

ry o

f

hype

rtens

ion.

Pre

mat

urity

, sle

ep d

isor

dere

d br

eath

ing

and

chro

nic

kidn

ey

dise

ase

are

also

maj

or ri

sk fa

ctor

s. T

here

may

als

o be

com

orbi

dity

with

diab

etes

mel

litus

.

Adu

lthoo

d A

vera

ge R

isk

Asy

mpt

omat

ic a

dults

age

d ≥18

year

s w

ithou

t kno

wn

hype

rtens

ion

with

or

with

out r

isk

fact

ors.

Hig

h R

isk

Per

sons

at i

ncre

ased

risk

for h

igh

bloo

d pr

essu

re a

re th

ose

who

hav

e el

evat

ed

bloo

d pr

essu

re (1

20-1

29/<

80 m

m H

g), t

hose

who

are

ove

rwei

ght o

r obe

se,

and

thos

e of

Afri

can

desc

ent.

Adu

lt Fe

mal

e du

ring

Preg

nanc

y A

vera

ge R

isk

P

regn

ant w

omen

with

out a

kno

wn

diag

nosi

s of

pre

-ecl

amps

ia.

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-2

Life

Cou

rse

Stag

e R

isk

Gro

up

Def

initi

on o

f the

Gro

up

Hig

h R

isk

All

clin

ical

con

ditio

ns a

ssoc

iate

d w

ith in

crea

sed

risk

incl

ude

a hi

stor

y of

ecla

mps

ia o

r pre

-ecl

amps

ia (p

artic

ular

ly e

arly

-ons

et p

re-e

clam

psia

), pr

evio

us

adve

rse

preg

nanc

y ou

tcom

e, m

ater

nal c

omor

bid

cond

ition

s (ty

pe 1

or 2

diab

etes

, ges

tatio

nal d

iabe

tes,

chr

onic

hyp

erte

nsio

n, re

nal d

isea

se, a

nd a

uto-

imm

une

dise

ases

), an

d m

ultif

oeta

l ges

tatio

n. O

ther

risk

fact

ors

incl

ude

nullip

arity

, obe

sity

, bei

ng o

f Afri

can

desc

ent,

low

soc

ioec

onom

ic s

tatu

s an

d

adva

nced

mat

erna

l age

.

Late

adu

lthoo

d (e

lder

ly)

Ave

rage

Ris

k A

sym

ptom

atic

adu

lts a

ged ≥60

year

s w

ithou

t kno

wn

hype

rtens

ion

with

or

with

out r

isk

fact

ors.

Hig

h R

isk

Per

sons

at i

ncre

ased

risk

for h

igh

bloo

d pr

essu

re a

re th

ose

who

hav

e el

evat

ed

bloo

d pr

essu

re (1

20-1

29/<

80 m

m H

g), t

hose

who

are

ove

rwei

ght o

r obe

se,

and

thos

e of

Afri

can

desc

ent.

(14)

(15)

(16)

C

ardi

ovas

cula

r Ris

k Pr

edic

tion

Use

of r

isk

pred

ictio

n ch

arts

to e

stim

ate

tota

l car

diov

ascu

lar r

isk

is a

maj

or a

dvan

ce o

n th

e ol

der p

ract

ice

of id

entif

ying

and

treat

ing

indi

vidu

al

risk

fact

ors,

su

ch

as

rais

ed

bloo

d pr

essu

re

(hyp

erte

nsio

n)

and

rais

ed

bloo

d ch

oles

tero

l

(hyp

erch

oles

tero

lem

ia).

The

tota

l ris

k ap

proa

ch a

ckno

wle

dges

tha

t m

any

card

iova

scul

ar r

isk

fact

ors

tend

to

appe

ar in

clus

ters

; com

bini

ng ri

sk fa

ctor

s to

pre

dict

tota

l car

diov

ascu

lar r

isk

is c

onse

quen

tly a

logi

cal a

ppro

ach

to d

ecid

ing

who

sho

uld

rece

ive

treat

men

t (39

).

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-3

W

HO

con

vene

d an

effo

rt to

dev

elop

, eva

luat

e an

d illu

stra

te re

vise

d ris

k m

odel

s to

hel

p ad

apt c

ardi

ovas

cula

r dis

ease

risk

pred

ictio

n ap

proa

ches

to lo

w-in

com

e an

d m

iddl

e-in

com

e co

untri

es. R

evis

ed W

HO

car

diov

ascu

lar

dise

ase

risk

pred

ictio

n

char

ts t

hat

have

bee

n ad

apte

d to

the

circ

umst

ance

s of

21

glob

al r

egio

ns (

7).

Cha

rts a

dapt

ed f

or C

arib

bean

cou

ntrie

s

(Ant

igua

and

Bar

buda

, B

aham

as,

Bel

ize,

Bar

bado

s, C

uba,

Dom

inic

a, D

omin

ican

Rep

ublic

, G

rena

da,

Guy

ana,

Hai

ti,

Jam

aica

, Sai

nt L

ucia

, Pue

rto R

ico,

Sur

inam

e, T

rinid

ad a

nd T

obag

o, S

aint

Vin

cent

and

the

Gre

nadi

nes)

are

pro

vide

d in

App

endi

x 3.

The

se c

hart

s ap

ply

to p

erso

ns ≥

40 y

ears

. Th

e ch

arts

pro

vide

onl

y ap

prox

imat

e es

timat

es o

f CV

D ri

sk in

peo

ple

who

do

not h

ave

sym

ptom

s of

cor

onar

y he

art

dise

ase

(CH

D) ,

stro

ke o

r oth

er a

ther

oscl

erot

ic d

isea

se. R

isk

pred

ictio

n ch

arts

may

tend

to u

nder

estim

ate

CV

risk

in

indi

vidu

als

who

hav

e al

read

y ex

perie

nced

a C

V e

vent

, or h

ave

very

hig

h le

vels

of i

ndiv

idua

l ris

k fa

ctor

s. T

hese

indi

vidu

als

alre

ady

belo

ng to

the

high

risk

cat

egor

y, a

nd in

clud

e in

divi

dual

s:

w

ith e

stab

lishe

d an

gina

pec

toris

, cor

onar

y he

art d

isea

se, m

yoca

rdia

l inf

arct

ion,

tran

sien

t isc

haem

ic a

ttack

s, s

troke

,

or p

erip

hera

l vas

cula

r dis

ease

, or w

ho h

ave

had

coro

nary

reva

scul

ariz

atio

n or

car

otid

end

arte

rect

omy

w

ith le

ft ve

ntric

ular

hyp

ertro

phy

(sho

wn

on e

lect

roca

rdio

grap

h) o

r hyp

erte

nsiv

e re

tinop

athy

(gra

de II

I or I

V)

pe

rson

s w

ithou

t est

ablis

hed

CV

D w

ho h

ave

a to

tal c

hole

ster

ol ≥

8 m

mol

/l (3

20 m

g/dl

) or l

ow-d

ensi

ty li

popr

otei

n

(LD

L) c

hole

ster

ol ≥

6 m

mol

/l (2

40 m

g/dl

) or T

C/H

DL-

C ra

tio >

8

w

ithou

t est

ablis

hed

CVD

who

hav

e pe

rsis

tent

rais

ed b

lood

pre

ssur

e (>

160–

170/

100–

105

mm

Hg)

w

ith d

iabe

tes,

plu

s ov

ert n

ephr

opat

hy o

r oth

er signific

ant r

enal

dis

ease

w

ith k

now

n re

nal f

ailu

re o

r im

pairm

ent (

39)

Car

diov

ascu

lar R

isk

Ass

essm

ent

See

App

endi

x 3

for a

gui

de to

a c

ompr

ehen

sive

clin

ical

CV

ass

essm

ent.

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-4

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

2.2

Chi

ldho

od

and

Ado

lesc

ence

H

ealth

Pro

mot

ion

& P

reve

ntio

n

Edu

catio

n on

risk

fact

ors

of

Hyp

erte

nsio

n es

peci

ally

in

rela

tion

to d

iet,

exer

cise

, us

e of

alc

ohol

& to

bacc

o

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

, with

in

the

com

mun

ity.

Sch

ool

heal

th

prog

ram

mes

ar

e a

favo

urab

le e

ntry

poi

nt f

or te

stin

g fo

r w

hat

will

be

mos

tly

an

in-s

choo

l po

pula

tion

(sch

ool m

edic

al)

P

rom

ote

Jam

aica

Mov

es

Pro

gram

me

in S

choo

ls (

or

othe

r sch

ool-b

ased

pr

ogra

mm

e fo

r hea

lthy

lifes

tyle

pro

mot

ion)

Yes

Yes

Yes

A

dvoc

ate

for H

ealth

and

Fa

mily

Life

Edu

catio

n to

be

a pa

rt of

sch

ool c

urric

ulum

(li

fe s

kills

edu

catio

n)

Yes

Yes

Yes

A

dvoc

ate

for s

choo

l fe

edin

g pr

ogra

mm

es to

ha

ve b

alan

ced

diet

s an

d sc

hool

can

teen

pol

icie

s th

at lo

ok a

t hea

lthy

optio

ns

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

If

read

ing

is n

orm

al g

ive

date

for t

he

next

con

sult

acco

rdin

g to

risk

gro

up

Pat

ient

s w

ho a

re h

igh

risk

shou

ld b

e co

unse

lled

on th

eir r

isk

for

deve

lopi

ng C

VD

. Cou

nsel

ling

shou

ld

Ta

ke b

lood

pre

ssur

e w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f eve

ry tw

o ye

ars

N/A

Ye

s Ye

s

B

MI a

nnua

lly

N/A

Ye

s Ye

s

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-4

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

2.2

Chi

ldho

od

and

Ado

lesc

ence

H

ealth

Pro

mot

ion

& P

reve

ntio

n

Edu

catio

n on

risk

fact

ors

of

Hyp

erte

nsio

n es

peci

ally

in

rela

tion

to d

iet,

exer

cise

, us

e of

alc

ohol

& to

bacc

o

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

, with

in

the

com

mun

ity.

Sch

ool

heal

th

prog

ram

mes

ar

e a

favo

urab

le e

ntry

poi

nt f

or te

stin

g fo

r w

hat

will

be

mos

tly

an

in-s

choo

l po

pula

tion

(sch

ool m

edic

al)

P

rom

ote

Jam

aica

Mov

es

Pro

gram

me

in S

choo

ls (

or

othe

r sch

ool-b

ased

pr

ogra

mm

e fo

r hea

lthy

lifes

tyle

pro

mot

ion)

Yes

Yes

Yes

A

dvoc

ate

for H

ealth

and

Fa

mily

Life

Edu

catio

n to

be

a pa

rt of

sch

ool c

urric

ulum

(li

fe s

kills

edu

catio

n)

Yes

Yes

Yes

A

dvoc

ate

for s

choo

l fe

edin

g pr

ogra

mm

es to

ha

ve b

alan

ced

diet

s an

d sc

hool

can

teen

pol

icie

s th

at lo

ok a

t hea

lthy

optio

ns

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

If

read

ing

is n

orm

al g

ive

date

for t

he

next

con

sult

acco

rdin

g to

risk

gro

up

Pat

ient

s w

ho a

re h

igh

risk

shou

ld b

e co

unse

lled

on th

eir r

isk

for

deve

lopi

ng C

VD

. Cou

nsel

ling

shou

ld

Ta

ke b

lood

pre

ssur

e w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f eve

ry tw

o ye

ars

N/A

Ye

s Ye

s

B

MI a

nnua

lly

N/A

Ye

s Ye

s

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-5

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

fo

cus

on: d

iet (

redu

cing

sal

t int

ake,

in

corp

orat

ing

fruits

and

veg

etab

les

in th

eir d

iet,

redu

cing

fatty

food

s,

redu

cing

car

bona

ted

beve

rage

s);

toba

cco

cess

atio

n; p

hysi

cal a

ctiv

ity

See

Appe

ndix

1 (b

lood

pre

ssur

e re

fere

nce

valu

es fo

r chi

ldre

n an

d ad

oles

cent

s)

If th

e bl

ood

pres

sure

read

ing

is

elev

ated

a fu

ll m

edic

al (i

nclu

des

past

med

ical

his

tory

, fam

ily h

isto

ry

and

phys

ical

exa

min

atio

n, in

clud

ing

eye

exam

inat

ion)

and

wor

k up

(b

lood

cou

nt, r

enal

func

tion,

urin

e te

st, e

lect

roca

rdio

gram

) mus

t be

done

and

the

patie

nt re

ferre

d to

a

Spe

cial

ist C

linic

for a

ppro

pria

te c

are.

Se

e Ap

pend

ix 2

(BM

I-for

-age

cha

rt)

Hig

h R

isk:

Take

blo

od p

ress

ure

with

sp

hygm

oman

omet

er a

nd

appr

opria

te c

uff o

nce

per

year

N/A

Ye

s Ye

s

B

MI a

nnua

lly

N/A

Ye

s Ye

s

2.3

Adul

thoo

d H

ealth

Pro

mot

ion

& P

reve

ntio

n

Adv

ocat

e fo

r enf

orce

men

t of

toba

cco

legi

slat

ion

N

/A

N/A

N

/A

Hea

lth p

rom

otio

n do

ne a

t cur

ativ

e cl

inic

s, w

orkp

lace

s, c

lubs

, rel

igio

us

grou

ps e

tc.,

with

in th

e co

mm

unity

.

H

ealth

edu

catio

n on

risk

fa

ctor

s: s

mok

ing,

alc

ohol

us

e, d

iet a

nd e

xerc

ise

Yes

Yes

Yes

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-6

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

A

dvoc

ate

for s

pace

s fo

r ex

erci

se in

com

mun

ities

an

d w

orks

pace

s

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Ta

ke b

lood

pre

ssur

e re

adin

g w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f

Yes

Yes

Yes

Nor

mal

blo

od p

ress

ure

read

ing

is

SB

P<1

20m

mH

g, D

BP<

80m

mH

g

Ele

vate

d B

lood

Pre

ssur

e re

adin

g is

S

BP

≥12

0mm

Hg,

DB

P ≥8

0mm

Hg

If

read

ing

is n

orm

al g

ive

date

for t

he

next

con

sult

acco

rdin

g to

risk

gro

up

If th

e bl

ood

pres

sure

read

ing

is

elev

ated

the

full

med

ical

(inc

lude

s pa

st m

edic

al h

isto

ry, f

amily

his

tory

an

d ph

ysic

al e

xam

inat

ion

incl

udin

g ey

e ex

amin

atio

n) a

nd b

asic

wor

k up

(b

lood

cou

nt, r

enal

func

tion,

urin

e te

st, l

ipid

pro

file,

blo

od g

luco

se,

elec

troca

rdio

gram

) mus

t be

done

an

d th

e pa

tient

eva

luat

ed fo

r in

itiat

ion

of tr

eatm

ent.

A

ll ob

ese

pers

ons

and

othe

rs w

ho

fall

in th

e hi

gh ri

sk g

roup

sho

uld

be

B

MI a

nnua

lly

Yes

Yes

Yes

R

eadi

ng s

houl

d be

don

e on

ce a

nnua

lly

Yes

Yes

Yes

Hig

h R

isk:

Take

blo

od p

ress

ure

read

ing

with

sp

hygm

oman

omet

er a

nd

read

ing

shou

ld b

e do

ne a

t m

inim

um o

nce

annu

ally

, sp

ecia

l con

side

ratio

n fo

r pe

rson

s on

med

icat

ion

that

ha

ve e

leva

ted

bloo

d pr

essu

re s

houl

d ha

ve

read

ings

don

e at

eac

h cl

inic

enc

ount

er

Ta

ke fa

mily

his

tory

and

pe

rson

al h

isto

ry, e

spec

ially

fo

r per

sons

ove

r 50

year

s

Yes

Yes

Yes

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-6

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

A

dvoc

ate

for s

pace

s fo

r ex

erci

se in

com

mun

ities

an

d w

orks

pace

s

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Ta

ke b

lood

pre

ssur

e re

adin

g w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f

Yes

Yes

Yes

Nor

mal

blo

od p

ress

ure

read

ing

is

SB

P<1

20m

mH

g, D

BP<

80m

mH

g

Ele

vate

d B

lood

Pre

ssur

e re

adin

g is

S

BP

≥12

0mm

Hg,

DB

P ≥8

0mm

Hg

If

read

ing

is n

orm

al g

ive

date

for t

he

next

con

sult

acco

rdin

g to

risk

gro

up

If th

e bl

ood

pres

sure

read

ing

is

elev

ated

the

full

med

ical

(inc

lude

s pa

st m

edic

al h

isto

ry, f

amily

his

tory

an

d ph

ysic

al e

xam

inat

ion

incl

udin

g ey

e ex

amin

atio

n) a

nd b

asic

wor

k up

(b

lood

cou

nt, r

enal

func

tion,

urin

e te

st, l

ipid

pro

file,

blo

od g

luco

se,

elec

troca

rdio

gram

) mus

t be

done

an

d th

e pa

tient

eva

luat

ed fo

r in

itiat

ion

of tr

eatm

ent.

A

ll ob

ese

pers

ons

and

othe

rs w

ho

fall

in th

e hi

gh ri

sk g

roup

sho

uld

be

B

MI a

nnua

lly

Yes

Yes

Yes

R

eadi

ng s

houl

d be

don

e on

ce a

nnua

lly

Yes

Yes

Yes

Hig

h R

isk:

Take

blo

od p

ress

ure

read

ing

with

sp

hygm

oman

omet

er a

nd

read

ing

shou

ld b

e do

ne a

t m

inim

um o

nce

annu

ally

, sp

ecia

l con

side

ratio

n fo

r pe

rson

s on

med

icat

ion

that

ha

ve e

leva

ted

bloo

d pr

essu

re s

houl

d ha

ve

read

ings

don

e at

eac

h cl

inic

enc

ount

er

Ta

ke fa

mily

his

tory

and

pe

rson

al h

isto

ry, e

spec

ially

fo

r per

sons

ove

r 50

year

s

Yes

Yes

Yes

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-7

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

at fi

rst e

ncou

nter

. P

ay

atte

ntio

n to

his

tory

of

stro

ke, a

ngin

a/he

art a

ttack

, he

art f

ailu

re

coun

selle

d on

die

t, ex

erci

se, a

nd

lifes

tyle

cha

nges

and

refe

rred

to a

di

etic

ian/

nutri

tioni

st. T

hey

shou

ld

also

be

coun

selle

d on

the

risk

for

deve

lopi

ng C

VD

. If

abno

rmal

lipi

d, o

r blo

od g

luco

se

etc.

con

side

r ini

tiatio

n of

trea

tmen

t

BM

I ann

ually

Ye

s Ye

s Ye

s

Con

duct

test

ing

for l

ipid

pr

ofile

, blo

od g

luco

se,

mic

roal

bum

in a

nnua

lly

N/A

Ye

s Ye

s

2.4

Adul

t Fem

ale

durin

g Pr

egna

ncy

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on d

iet,

exer

cise

, sm

okin

g an

d al

coho

l use

Yes

Yes

Yes

E

duca

te o

n ea

rly

adm

issi

on in

to a

nten

atal

cl

inic

(bef

ore

12 w

eeks

) an

d co

ntin

uous

atte

ndan

ce

Yes

Yes

Yes

E

duca

te o

n hy

perte

nsio

n in

pr

egna

ncy

(dan

ger s

igns

) Ye

s

Yes

Yes

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-8

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk

Gro

up:

Nor

mal

Blo

od P

ress

ure

read

ing

is

SB

P <

120m

mH

g, D

BP

<80m

mH

g

Ele

vate

d B

lood

Pre

ssur

e re

adin

g is

S

BP

≥14

0mm

Hg,

DB

P ≥9

0mm

Hg

If

read

ing

is n

orm

al g

ive

date

for t

he

next

con

sult

acco

rdin

g to

risk

gro

up.

Pat

ient

s w

ith fa

mily

his

tory

and

pe

rson

al h

isto

ry s

houl

d be

adv

ised

on

dan

ger s

igns

of P

regn

ancy

In

duce

d H

yper

tens

ion

and

thei

r CV

ris

k If

the

bloo

d pr

essu

re is

ele

vate

d th

e ba

sic

wor

k up

(blo

od c

ount

, ren

al

func

tion

test

, urin

e te

st, l

ipid

pro

file,

bl

ood

gluc

ose,

ele

ctro

card

iogr

am)

shou

ld b

e do

ne a

nd th

e pa

tient

re

ferre

d to

an

Obs

tetri

c S

peci

alis

t (h

igh

risk)

Clin

ic fo

r fur

ther

m

anag

emen

t acc

ordi

ng to

obs

tetri

c gu

idel

ines

Ta

ke b

lood

pre

ssur

e re

adin

g w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f

Yes

Yes

Yes

R

eadi

ng s

houl

d be

don

e at

ev

ery

clin

ic v

isit

Ta

ke fa

mily

his

tory

and

pe

rson

al h

isto

ry a

t firs

t en

coun

ter.

Pay

atte

ntio

n to

his

tory

of s

troke

, ang

ina/

he

art a

ttack

, hea

rt fa

ilure

N/A

Ye

s Ye

s

U

rine

prot

ein

at e

very

clin

ic

visi

t N

/A

Yes

Yes

B

MI a

nnua

lly

N/A

Ye

s Ye

s H

igh

Ris

k G

roup

:

Take

blo

od p

ress

ure

read

ing

with

sp

hygm

oman

omet

er a

nd

appr

opria

te c

uff (

with

pa

tient

sea

ted

for a

t lea

st 5

m

inut

es b

efor

e re

adin

g is

ta

ken)

.

Take

fam

ily h

isto

ry a

nd

pers

onal

his

tory

at f

irst

enco

unte

r. P

ay a

ttent

ion

to

N/A

Ye

s Ye

s

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-8

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk

Gro

up:

Nor

mal

Blo

od P

ress

ure

read

ing

is

SB

P <

120m

mH

g, D

BP

<80m

mH

g

Ele

vate

d B

lood

Pre

ssur

e re

adin

g is

S

BP

≥14

0mm

Hg,

DB

P ≥9

0mm

Hg

If

read

ing

is n

orm

al g

ive

date

for t

he

next

con

sult

acco

rdin

g to

risk

gro

up.

Pat

ient

s w

ith fa

mily

his

tory

and

pe

rson

al h

isto

ry s

houl

d be

adv

ised

on

dan

ger s

igns

of P

regn

ancy

In

duce

d H

yper

tens

ion

and

thei

r CV

ris

k If

the

bloo

d pr

essu

re is

ele

vate

d th

e ba

sic

wor

k up

(blo

od c

ount

, ren

al

func

tion

test

, urin

e te

st, l

ipid

pro

file,

bl

ood

gluc

ose,

ele

ctro

card

iogr

am)

shou

ld b

e do

ne a

nd th

e pa

tient

re

ferre

d to

an

Obs

tetri

c S

peci

alis

t (h

igh

risk)

Clin

ic fo

r fur

ther

m

anag

emen

t acc

ordi

ng to

obs

tetri

c gu

idel

ines

Ta

ke b

lood

pre

ssur

e re

adin

g w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f

Yes

Yes

Yes

R

eadi

ng s

houl

d be

don

e at

ev

ery

clin

ic v

isit

Ta

ke fa

mily

his

tory

and

pe

rson

al h

isto

ry a

t firs

t en

coun

ter.

Pay

atte

ntio

n to

his

tory

of s

troke

, ang

ina/

he

art a

ttack

, hea

rt fa

ilure

N/A

Ye

s Ye

s

U

rine

prot

ein

at e

very

clin

ic

visi

t N

/A

Yes

Yes

B

MI a

nnua

lly

N/A

Ye

s Ye

s H

igh

Ris

k G

roup

:

Take

blo

od p

ress

ure

read

ing

with

sp

hygm

oman

omet

er a

nd

appr

opria

te c

uff (

with

pa

tient

sea

ted

for a

t lea

st 5

m

inut

es b

efor

e re

adin

g is

ta

ken)

.

Take

fam

ily h

isto

ry a

nd

pers

onal

his

tory

at f

irst

enco

unte

r. P

ay a

ttent

ion

to

N/A

Ye

s Ye

s

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-9

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

hist

ory

of s

troke

, ang

ina/

he

art a

ttack

, hea

rt fa

ilure

an

d al

so p

regn

ancy

in

duce

d hy

perte

nsio

n

R

eadi

ng s

houl

d be

don

e at

ev

ery

clin

ic v

isit

N/A

Ye

s Ye

s

U

rine

prot

ein

at e

very

clin

ic

visi

t N

/A

Yes

Yes

2.5

Late

A

dulth

ood

(Eld

erly

)

Hea

lth P

rom

otio

n &

Pre

vent

ion

H

ealth

edu

catio

n on

risk

fa

ctor

s: s

mok

ing,

alc

ohol

us

e, d

iet a

nd e

xerc

ise

Yes

Yes

Yes

Eld

erly

can

be

seen

at t

he le

vel o

f th

e co

mm

unity

whi

ch in

clud

es

elde

rly c

lubs

, eld

erly

resi

dent

ial

faci

litie

s, a

nd o

ther

org

aniz

atio

ns.

A

dvoc

ate

for s

pace

s fo

r ex

erci

se in

com

mun

ities

w

ith s

peci

al a

men

ities

to

cate

r to

this

pop

ulat

ion

Yes

Yes

Yes

A

dvoc

ate

for T

obac

co

legi

slat

ion

Ye

s Ye

s Ye

s

A

dvoc

ate

for r

esid

entia

l fa

cilit

ies

for t

he e

lder

ly to

ha

ve p

olic

ies

that

add

ress

nu

tritio

n an

d ex

erci

se fo

r th

e el

derly

N/A

N/A

N

/A

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-10

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk

Gro

up:

A fu

ll hi

stor

y sh

ould

be

take

n fro

m

the

elde

rly p

atie

nt in

clus

ive

of

sym

ptom

s of

car

diov

ascu

lar e

vent

s su

ch a

s st

roke

(sud

den

wea

knes

s,

conf

usio

n, v

isio

n pr

oble

ms,

diff

icul

ty

wal

king

, etc

), m

yoca

rdia

l inf

arct

ion

and

angi

na (c

hest

pai

n, ti

ghtn

ess,

di

scom

fort,

sho

rtnes

s of

bre

ath)

N

orm

al B

lood

Pre

ssur

e re

adin

g is

S

BP

< 1

20m

mhH

g, D

BP

<

80m

mH

g.

Ele

vate

d B

lood

Pre

ssur

e re

adin

g is

S

BP

≥14

0mm

Hg,

DB

P ≥9

0mm

Hg

If re

adin

g is

nor

mal

giv

e da

te fo

r the

ne

xt c

onsu

lt ac

cord

ing

to ri

sk g

roup

If

the

bloo

d pr

essu

re re

adin

g is

el

evat

ed, t

he fu

ll m

edic

al (w

hich

in

clud

es p

ast m

edic

al h

isto

ry, f

amily

hi

stor

y an

d ph

ysic

al e

xam

inat

ion)

pl

us w

ork

up (b

lood

cou

nt, r

enal

fu

nctio

n, u

rine

test

, lip

id p

rofil

e,

bloo

d gl

ucos

e, e

lect

roca

rdio

gram

)

Ta

ke b

lood

pre

ssur

e re

adin

g w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f (w

ith

patie

nt s

eate

d fo

r at l

east

5

min

utes

bef

ore

read

ing

is

take

n).

Yes

Yes

Yes

B

MI a

nnua

lly

Yes

Yes

Yes

R

eadi

ng s

houl

d be

don

e on

ce a

nnua

lly

Yes

Yes

Yes

Hig

h R

isk

Gro

up:

Ta

ke b

lood

pre

ssur

e re

adin

g w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f

Yes

Yes

Yes

R

eadi

ng s

houl

d be

don

e at

m

inim

um o

nce

annu

ally

; sp

ecia

l con

side

ratio

n fo

r pe

rson

s on

med

icat

ion

that

ca

n in

crea

se b

lood

pr

essu

re w

ho s

houl

d ha

ve

read

ings

don

e at

eac

h cl

inic

enc

ount

er

N/A

Ye

s Ye

s

B

MI a

nnua

lly

Ye

s Ye

s Ye

s

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-10

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk

Gro

up:

A fu

ll hi

stor

y sh

ould

be

take

n fro

m

the

elde

rly p

atie

nt in

clus

ive

of

sym

ptom

s of

car

diov

ascu

lar e

vent

s su

ch a

s st

roke

(sud

den

wea

knes

s,

conf

usio

n, v

isio

n pr

oble

ms,

diff

icul

ty

wal

king

, etc

), m

yoca

rdia

l inf

arct

ion

and

angi

na (c

hest

pai

n, ti

ghtn

ess,

di

scom

fort,

sho

rtnes

s of

bre

ath)

N

orm

al B

lood

Pre

ssur

e re

adin

g is

S

BP

< 1

20m

mhH

g, D

BP

<

80m

mH

g.

Ele

vate

d B

lood

Pre

ssur

e re

adin

g is

S

BP

≥14

0mm

Hg,

DB

P ≥9

0mm

Hg

If re

adin

g is

nor

mal

giv

e da

te fo

r the

ne

xt c

onsu

lt ac

cord

ing

to ri

sk g

roup

If

the

bloo

d pr

essu

re re

adin

g is

el

evat

ed, t

he fu

ll m

edic

al (w

hich

in

clud

es p

ast m

edic

al h

isto

ry, f

amily

hi

stor

y an

d ph

ysic

al e

xam

inat

ion)

pl

us w

ork

up (b

lood

cou

nt, r

enal

fu

nctio

n, u

rine

test

, lip

id p

rofil

e,

bloo

d gl

ucos

e, e

lect

roca

rdio

gram

)

Ta

ke b

lood

pre

ssur

e re

adin

g w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f (w

ith

patie

nt s

eate

d fo

r at l

east

5

min

utes

bef

ore

read

ing

is

take

n).

Yes

Yes

Yes

B

MI a

nnua

lly

Yes

Yes

Yes

R

eadi

ng s

houl

d be

don

e on

ce a

nnua

lly

Yes

Yes

Yes

Hig

h R

isk

Gro

up:

Ta

ke b

lood

pre

ssur

e re

adin

g w

ith

sphy

gmom

anom

eter

and

ap

prop

riate

cuf

f

Yes

Yes

Yes

R

eadi

ng s

houl

d be

don

e at

m

inim

um o

nce

annu

ally

; sp

ecia

l con

side

ratio

n fo

r pe

rson

s on

med

icat

ion

that

ca

n in

crea

se b

lood

pr

essu

re w

ho s

houl

d ha

ve

read

ings

don

e at

eac

h cl

inic

enc

ount

er

N/A

Ye

s Ye

s

B

MI a

nnua

lly

Ye

s Ye

s Ye

s

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-11

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

HYP

ERTE

NSI

ON

St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Con

duct

test

ing

for l

ipid

pr

ofile

, blo

od g

luco

se,

mic

roal

bum

in a

nnua

lly

Ta

ke fa

mily

his

tory

and

pe

rson

al h

isto

ry.

Pay

at

tent

ion

to h

isto

ry o

f st

roke

, ang

ina/

hear

t atta

ck,

hear

t fai

lure

N/A

Ye

s Ye

s m

ust b

e do

ne a

nd th

e pa

tient

re

ferre

d to

chr

onic

dis

ease

clin

ic.

For t

hose

alre

ady

in a

Spe

cial

ist

Clin

ic fo

r any

clin

ical

con

ditio

n th

at

pred

ispo

ses

them

to d

evel

op

hype

rtens

ion

as a

sec

onda

ry

cond

ition

, con

sulta

tion

with

the

inte

rnal

med

icin

e sp

ecia

list o

n ap

prop

riate

man

agem

ent o

f thi

s co

nditi

on is

reco

mm

ende

d.

All

obes

e pe

rson

s an

d ot

hers

who

fa

ll in

the

high

risk

gro

up s

houl

d be

co

unse

lled

on d

iet,

exer

cise

, and

lif

esty

le c

hang

es a

nd re

ferre

d to

a

diet

icia

n/nu

tritio

nist

. The

y sh

ould

al

so b

e co

unse

lled

on th

eir r

isk

for

deve

lopi

ng C

VD

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-12

Fi

gure

1: A

lgor

ithm

for S

cree

ning

, Ref

erra

l and

Fol

low

Up

in C

hild

ren

and

Adol

esce

nts

at A

vera

ge a

nd H

igh

Ris

k fo

r Hig

h B

lood

Pre

ssur

e

Abb

revi

atio

ns: P

HC

, prim

ary

heal

th c

are,

-ve,

neg

ativ

e (<

120/

<80

mm

Hg)

, +ve

, pos

itive

(>12

0/>8

0 m

m H

g)

*at d

iffer

ent t

imes

, diff

eren

t set

tings

if p

ossi

ble

**

See

App

endi

x 3

for W

HO

CV

risk

pre

dict

ion

char

ts a

nd c

linic

al a

sses

smen

t gui

de

Hig

h R

isk:

Ele

vate

d bo

dy m

ass

inde

x (B

MI).

Oth

er ri

sk fa

ctor

s in

clud

e:

•Lo

w b

irth

wei

ght

•M

ale

sex

•E

thni

city

(Afri

can

desc

ent)

•Fa

mily

his

tory

of h

yper

tens

ion

•P

rem

atur

ity

•S

leep

dis

orde

red

brea

thin

g

•C

hron

ic k

idne

y di

seas

e

•Th

ere

may

als

o be

com

orbi

dity

with

di

abet

es m

ellit

us

Ref

erra

l to

inte

rnal

m

edic

ine/

pae

diat

ric

clin

ic d

epen

dent

on

age*

**

Full

med

ical

pr

ofile

in P

HC

**R

epea

t BP

twic

e*

Res

cree

n:

- Ave

rage

risk

: eve

ry 2

yea

rs- H

igh

risk:

ann

ually

Asy

mpt

omat

ic

3 to

< 1

9 ye

ars

BP

mea

sure

men

t &

CV

risk

asse

ssm

ent

-ve

+ ve

-ve

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-12

Fi

gure

1: A

lgor

ithm

for S

cree

ning

, Ref

erra

l and

Fol

low

Up

in C

hild

ren

and

Adol

esce

nts

at A

vera

ge a

nd H

igh

Ris

k fo

r Hig

h B

lood

Pre

ssur

e

Abb

revi

atio

ns: P

HC

, prim

ary

heal

th c

are,

-ve,

neg

ativ

e (<

120/

<80

mm

Hg)

, +ve

, pos

itive

(>12

0/>8

0 m

m H

g)

*at d

iffer

ent t

imes

, diff

eren

t set

tings

if p

ossi

ble

**

See

App

endi

x 3

for W

HO

CV

risk

pre

dict

ion

char

ts a

nd c

linic

al a

sses

smen

t gui

de

CH

APT

ER2:

SCR

EEN

ING

GU

IDEL

INE

FOR

HYP

ERTE

NS

ION

&C

VDD

ate

Issu

ed:

()R

evis

ed

()

New

Page

2-13

Figu

re 2

:Alg

orith

m, S

cree

ning

, Ref

erra

l and

Fol

low

Up

in A

dults

at A

vera

ge a

nd H

igh

Ris

k fo

r Hig

h B

lood

Pr

essu

re a

nd C

VD R

isk

Abb

revi

atio

ns: P

HC

, prim

ary

heal

th c

are,

-ve,

neg

ativ

e (<

120/

<80

mm

Hg)

, +ve

, pos

itive

(>12

0/>8

0 m

m H

g)*a

t diff

eren

t tim

es, d

iffer

ent s

ettin

gs if

pos

sibl

e **

See

App

endi

x 3

for W

HO

CV

risk

pre

dict

ion

char

ts a

nd c

linic

al a

sses

smen

t gui

de

Asy

mpt

omat

ic

≥20

year

sB

P m

easu

rem

ent

CVD

RIS

K m

easu

rem

ent*

*

+ve

↑BP

refe

r

+ve

↑BP

Rep

eat

twic

e* -ve:

resc

reen

at e

very

visi

t & d

epen

dent

on

CVD

R

ISK

and

dia

gnos

is

Act

ions

to ↓

ris

k is

de

pend

ent o

n C

VD R

ISK

an

d di

agno

sis

Full

med

ical

pr

ofile

PH

C li

nk

to

trea

tmen

t gu

idel

ines

-ve

If av

erag

e ris

k <4

0 y

asse

ssed

an

d tr

eate

d b

y PH

C if

no

t due

to 2

o ca

use

If hi

gh ri

sk o

r du

e to

2o c

ause

or

com

plic

atio

n a

t dia

gnos

is

refe

r to

spec

ialis

t

If >4

0 Av

erag

e ris

k-as

sess

ed

and

trea

ted

by

PHC

Hig

h R

isk

•O

verw

eigh

t or

Obe

se•

Afri

can

desc

ent

•Fa

mily

his

tory

Aver

age

Ris

k

•≥18years

nil h

isto

ry o

f hy

perte

nsio

n •

No

risk

fact

ors

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-14

Fi

gure

3: A

lgor

ithm

for S

cree

ning

, Ref

erra

l and

Fol

low

up

in P

regn

ant W

omen

at A

vera

ge a

nd H

igh

Ris

k fo

r Hig

h B

lood

Pre

ssur

e an

d C

VD R

isk

Abb

revi

atio

ns: *

at d

iffer

ent t

imes

(30

min

s or

mor

e ap

art),

diff

eren

t set

tings

if p

ossi

ble

*F

MP

-HB

P, f

ull m

edic

al p

rofil

e fo

r hig

h bl

ood

pres

sure

; PH

C, p

rimar

y he

alth

car

e; -v

e, n

egat

ive

(SB

P <

140m

mH

g or

DB

P<9

0 be

fore

or a

fter 2

0 w

eeks

ges

tatio

n); +

ve, p

ositi

ve (S

BP

≥140

or DBP≥90m

mHg

befo

re o

r afte

r 20

wee

ks g

esta

tion)

**

for t

he p

regn

ant t

eena

ger

Asy

mpt

omat

ic

>18y

Wom

an

in p

regn

ancy

Av

erag

e an

d H

igh

Ris

k

BP

Mea

sure

men

t

CVD

risk

mea

sure

men

t 6-8

w

eeks

to 1

yea

r po

stpa

rtum

Act

ions

to ri

sk is

de

pend

ent o

n C

VD

risk

and

diag

nosi

s &

follo

w-u

p

FMP-

HB

P in

PH

C L

ink

to tr

eatm

ent

guid

elin

e

**M

ore

freq

uent

sc

reen

ing

sche

dule

of a

nten

atal

vis

its

refe

r

Res

cree

n an

d re

peat

blo

od

pres

sure

at e

very

ant

enat

al v

isit*

*

Rep

eat*

+ve

follo

w

up+v

e

-ve

Hig

h R

isk:

•H

isto

ry o

f ecl

amps

ia/ p

re-e

clam

psia

•M

ultif

oeta

l ges

tatio

n•

Pre

viou

s ad

vers

e m

ater

nal o

utco

me

•O

besi

ty•

Nul

lipar

ity•

Adv

ance

d m

ater

nal a

ge•

Com

orbi

d co

nditi

ons;

dia

bete

s au

toim

mun

e di

sord

er, e

tc.

•A

frica

n de

scen

t

Hig

h ris

k an

tena

tal

clin

ic

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-14

Fi

gure

3: A

lgor

ithm

for S

cree

ning

, Ref

erra

l and

Fol

low

up

in P

regn

ant W

omen

at A

vera

ge a

nd H

igh

Ris

k fo

r Hig

h B

lood

Pre

ssur

e an

d C

VD R

isk

Abb

revi

atio

ns: *

at d

iffer

ent t

imes

(30

min

s or

mor

e ap

art),

diff

eren

t set

tings

if p

ossi

ble

*F

MP

-HB

P, f

ull m

edic

al p

rofil

e fo

r hig

h bl

ood

pres

sure

; PH

C, p

rimar

y he

alth

car

e; -v

e, n

egat

ive

(SB

P <

140m

mH

g or

DB

P<9

0 be

fore

or a

fter 2

0 w

eeks

ges

tatio

n); +

ve, p

ositi

ve (S

BP

≥140

or DBP≥90m

mHg

befo

re o

r afte

r 20

wee

ks g

esta

tion)

**

for t

he p

regn

ant t

eena

ger

CH

APT

ER 2

:

SCR

EEN

ING

GU

IDEL

INE

FO

R H

YPER

TEN

SIO

N

& C

VD

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 2

-15

Fi

gure

4: A

lgor

ithm

for S

cree

ning

, Ref

erra

l and

Fol

low

Up

in th

e El

derly

at A

vera

ge a

nd H

igh

Ris

k fo

r Hig

h B

lood

Pr

essu

re a

nd C

VD R

isk

Abb

revi

atio

ns: F

MP-

HB

P, f

ull m

edic

al p

rofil

e fo

r hig

h bl

ood

pres

sure

; PH

C, p

rimar

y he

alth

car

e; -v

e, n

egat

ive

(<12

0/<8

0 m

mH

g); +

ve,

posi

tive (≥120/≥80

mm

Hg)

*a

t diff

eren

t tim

es (3

0 m

ins

or m

ore

apar

t), d

iffer

ent s

ettin

gs if

pos

sibl

e

**S

ee A

ppen

dix

3 fo

r WH

O C

V ri

sk p

redi

ctio

n ch

arts

and

clin

ical

ass

essm

ent g

uide

Ref

erra

l to

Chr

onic

D

isea

se C

linic

, for

pe

rson

s w

ith

Hyp

erte

nsio

n as

a

com

plic

atio

n of

a

pre-

exis

ting

cond

ition

and

al-

read

y in

a s

peci

alty

cl

inic

con

sult

with

In

tern

al M

edic

ine

Hig

h R

isk

•O

verw

eigh

t or O

bese

•A

frica

n de

scen

t•

Ele

vate

d B

P (1

20-1

29

mm

Hg)

Aver

age

Ris

k

•≥60yearsnilhistoryof

hype

rtens

ion

•N

o ris

k fa

ctor

s

BP

mea

sure

men

t &

CV

RIS

K

asse

ssm

ent*

*

Res

cree

n at

nex

t clin

ic v

isit

for p

erso

ns w

ith h

igh

risk

and

once

ann

ually

for p

er-

sons

with

low

er ri

sk

Rep

eat B

lood

pr

essu

re re

adin

g tw

ice*

FMP-

HB

P in

PH

C

Link

to tr

eatm

ent

guid

elin

e+v

e

-ve

+ve

Asy

mpt

omat

ic

60y

and

olde

r

-ve

S

UB

JEC

T: S

CR

EE

NIN

G G

UID

ELI

NE

S FO

R P

RIO

RIT

Y N

CD

s

PA

GE

3-1

Cha

pter

3 S

CR

EE

NIN

G G

UID

ELI

NE

S F

OR

DE

PR

ESS

ION

D

ATE

ISS

UE

D:

(

) R

evis

ed (

) N

ew

3.

1 R

isk

Gro

ups

and

Spec

ial C

onsi

dera

tions

for D

epre

ssio

n Sc

reen

ing

Life

Cou

rse

Stag

e R

isk

Gro

up

Def

initi

on o

f the

Gro

up

Ado

lesc

ence

A

vera

ge R

isk

No

hist

ory

of c

hron

ic il

lnes

s or

men

tal d

isor

der,

activ

e in

sch

ool a

nd

othe

r soc

ial a

ctiv

ities

, goo

d fa

mily

sup

port

(dua

l par

ents

’ hom

es).

Hig

h R

isk

Sin

gle

pare

nt h

omes

, his

tory

of c

hron

ic il

lnes

s or

men

tal d

isor

der,

abus

e, s

igni

fican

t tra

umat

ic li

fe e

vent

whi

ch in

clud

es re

loca

tions

, new

sc

hool

, new

com

mun

ity, s

epar

atio

n of

par

ents

, sub

stan

ce a

buse

, poo

r so

cioe

cono

mic

bac

kgro

und,

low

inco

me

hous

ehol

ds, p

erso

nal h

isto

ry

of te

enag

e pr

egna

ncy,

sex

ual m

inor

ities

. Chi

ldre

n in

sta

te c

are.

A

dulth

ood

Ave

rage

Ris

k M

ale,

no

pers

onal

or f

amily

his

tory

of m

enta

l dis

orde

r, go

od s

ocia

l and

fa

mily

sup

port,

em

ploy

ed, m

arrie

d.

Hig

h R

isk

Pat

ient

s w

ith o

ther

NC

Ds,

fem

ale,

per

sona

l or f

amily

his

tory

of m

enta

l di

sord

er, p

erso

ns w

ith d

isab

ilitie

s, p

oor s

ocio

econ

omic

bac

kgro

und,

low

in

com

e, s

ingl

e pa

rent

hood

, sex

ual m

inor

ities

, poo

r soc

ial a

nd fa

mily

su

ppor

t, hi

stor

y of

neg

ativ

e lif

e ev

ent

such

as

loss

of a

clo

se fr

iend

or

rela

tive,

rela

tions

hip

disp

utes

, int

imat

e pa

rtner

vio

lenc

e, jo

b lo

ss, e

tc.

Preg

nant

/ Pos

t-Par

tum

Fe

mal

es

Ave

rage

Ris

k M

arrie

d, g

ood

fam

ily s

uppo

rt, n

o hi

stor

y of

chr

onic

dis

ease

and

men

tal

illnes

s, g

ood

soci

oeco

nom

ic b

ackg

roun

d, e

mpl

oyed

.

Hig

h R

isk

Pat

ient

s w

ith o

ther

NC

Ds,

une

mpl

oyed

, his

tory

of c

hron

ic il

lnes

ses,

hi

stor

y of

sub

stan

ce a

buse

, pre

viou

s pe

rson

al h

isto

ry o

f pos

tpar

tum

de

pres

sion

, chi

ldca

re s

tress

, uni

nten

ded

preg

nanc

y, p

oor s

elf-e

stee

m,

low

soc

ioec

onom

ic b

ackg

roun

d, re

latio

nshi

p di

sput

es, i

ntim

ate

partn

er

viol

ence

, ado

lesc

ent p

regn

ancy

, poo

r fam

ily s

uppo

rt.

Late

adu

lthoo

d (e

lder

ly)

Ave

rage

Ris

k N

o hi

stor

y of

chr

onic

illn

ess,

no

pers

onal

nor

fam

ily h

isto

ry o

f men

tal

diso

rder

, phy

sica

lly a

nd s

ocia

lly a

ctiv

e.

CH

AP

TER

3:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DE

PR

ES

SIO

N

Dat

e Is

sued

: (

)Rev

ised

( )

New

P

age

3-2

Li

fe C

ours

e St

age

Ris

k G

roup

D

efin

ition

of t

he G

roup

H

igh

Ris

k R

isks

are

sim

ilar t

o th

at o

f the

adu

lt gr

oup.

Oth

ers

incl

ude

patie

nts

with

ot

her N

CD

s, p

hysi

cal d

isab

ility,

no

child

ren

and

lack

of f

amily

and

soc

ial

supp

ort.

Spec

ial C

onsi

dera

tions

A

ll ch

ildre

n an

d ad

oles

cent

s w

ho a

re s

uspe

cted

of d

epre

ssio

n sh

ould

be

refe

rred

to a

S

peci

alis

t Clin

ic. A

dole

scen

ts a

nd c

hild

ren

may

pre

sent

with

non

-typi

cal p

rese

ntat

ions

suc

h as

in

crea

sed

aggr

essi

on, w

ithdr

awal

, dec

reas

ed p

erfo

rman

ce in

sch

ool e

tc.

Take

a d

etai

led

hist

ory

of p

revi

ous

epis

odes

of m

ajor

dep

ress

ion,

fam

ily h

isto

ry, h

isto

ry o

f dru

g us

e, c

urre

nt m

edic

atio

n, a

nd p

revi

ous

resp

onse

to a

ntid

epre

ssan

ts.

Ask

abo

ut v

eget

ativ

e sy

mpt

oms

(sle

ep, a

ppet

ite, l

ibid

o).

A

lway

s ev

alua

te s

uici

de ri

sk. M

edic

al P

rofil

e fo

r dep

ress

ion

incl

udes

full

phys

ical

exa

min

atio

n to

rule

out

oth

er d

isor

ders

. Inv

estig

atio

ns m

ay in

clud

e: C

ompl

ete

Blo

od C

ount

, Blo

od C

hem

istry

(U

E) R

enal

Fun

ctio

n Te

st, G

luco

se a

nd E

ndoc

rine

pane

l eg.

Thy

roid

Fun

ctio

n Te

st, B

asic

Dru

g S

cree

ning

(Alc

ohol

, Coc

aine

, Mar

ijuan

a, H

eroi

ne).

O

ther

inve

stig

atio

ns s

uch

as C

T B

rain

Sca

n m

ay b

e in

dica

ted

base

d on

neu

rolo

gica

l ex

amin

atio

n fin

ding

s.

See

Appe

ndix

4

Patie

nt H

ealth

Q

uest

ionn

aire

(PH

Q)-2

(1

) Dur

ing

the

past

mon

th, h

ave

you

been

bot

here

d m

ost o

f the

tim

e by

feel

ing

dow

n,

depr

esse

d or

hop

eles

s?

• Y

es

•

No

(2

) Dur

ing

the

past

mon

th, h

ave

you

been

bot

here

d m

ost o

f the

tim

e by

hav

ing

little

inte

rest

or

plea

sure

in d

oing

thin

gs?

• Y

es

•

No

If

“No”

to b

oth,

pat

ient

is u

nlik

ely

to h

ave

maj

or d

epre

ssio

n. If

“Yes

” to

eith

er, p

roce

ed w

ith

the

follo

w u

p m

edic

al p

rofil

e an

d P

HQ

-9 (S

ee A

ppen

dix

4 an

d A

ppen

dix

6)

(17)

,(18)

,(19)

CH

AP

TER

3:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DE

PR

ES

SIO

N

Dat

e Is

sued

: (

)Rev

ised

( )

New

P

age

3-3

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

Dep

ress

ion

Stag

e ac

ross

th

e Li

fe C

ours

e

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

3.2

Ado

lesc

ence

H

ealth

Pro

mot

ion

& P

reve

ntio

n

Edu

catio

n on

Men

tal H

ealth

and

D

epre

ssio

n (s

igns

& s

ympt

oms,

ris

k fa

ctor

s, s

cree

ning

)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

, with

in

the

com

mun

ity.

Edu

catio

n on

stra

tegi

es to

m

aint

ain

good

men

tal h

ealth

Ye

s Ye

s Ye

s

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Scr

een

annu

ally

with

KA

DS

-6

If

KA

DS

-6 n

egat

ive,

sco

re <

6 (re

peat

ann

ually

)

N/A

Ye

s Ye

s A

ny c

hang

e in

ado

lesc

ents

’ be

havi

ours

, sui

cida

l int

ent o

r su

spec

ted

mod

erat

e to

sev

ere

case

s of

dep

ress

ion

shou

ld b

e re

ferre

d to

a S

peci

alis

t Clin

ic.

See

App

endi

x 5

for K

AD-6

Fu

ll m

edic

al p

rofil

e in

clud

es

com

preh

ensi

ve h

isto

ry, m

enta

l st

atus

eva

luat

ion,

phy

sica

l ex

amin

atio

n, a

nd in

vest

igat

ions

. S

ee A

ppen

dix

4

If

posi

tive

a sc

ore

6 or

>, c

arry

ou

t ful

l med

ical

pro

file

(if n

o ot

her c

ause

det

ecte

d) a

nd re

fer

to a

Spe

cial

ist C

linic

N/A

Ye

s Ye

s

Hig

h R

isk:

Scr

een

thre

e tim

es y

early

with

K

AD

S-6

If K

AD

S-6

neg

ativ

e, re

peat

in 4

m

onth

s

N/A

Ye

s Ye

s

If

KA

DS

-6 p

ositi

ve, c

arry

out

full

med

ical

pro

file

(if n

o ot

her c

ause

de

tect

ed) a

nd re

fer t

o a

Spe

cial

ist C

linic

N/A

Ye

s Ye

s

CH

AP

TER

3:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DE

PR

ES

SIO

N

Dat

e Is

sued

: (

)Rev

ised

( )

New

P

age

3-4

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

Dep

ress

ion

Stag

e ac

ross

th

e Li

fe C

ours

e

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

3.3

Adu

lthoo

d H

ealth

Pro

mot

ion

& P

reve

ntio

n

Edu

catio

n on

Men

tal H

ealth

and

D

epre

ssio

n (s

igns

& s

ympt

oms,

ris

k fa

ctor

s, s

cree

ning

)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t w

orkp

lace

s, c

lubs

, rel

igio

us g

roup

s et

c., w

ithin

the

com

mun

ity.

Edu

catio

n on

stra

tegi

es to

m

aint

ain

good

men

tal h

ealth

Ye

s Ye

s Ye

s

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

S

cree

n an

nual

ly w

ith P

HQ

-2

If

PH

Q-2

neg

ativ

e, re

peat

an

nual

ly

N/A

Ye

s Ye

s P

HQ

-2 p

ositi

ve m

eans

the

patie

nt

has

a po

sitiv

e re

spon

se to

eith

er

ques

tion

PH

Q-2

neg

ativ

e m

eans

the

patie

nt

resp

onds

“no”

to b

oth

ques

tions

. P

HQ

-9 is

pos

itive

if th

e pa

tient

has

a

scor

e of

5 a

nd a

bove

P

HQ

-9 is

neg

ativ

e if

the

patie

nt h

as

a sc

ore

of le

ss th

an 5

S

ee A

ppen

dix

4 fo

r Ful

l med

ical

pr

ofile

S

ee A

ppen

dix

6 fo

r PH

Q-9

C

ompl

ex c

ases

incl

ude:

Pat

ient

s w

ho a

re p

ersi

sten

tly s

uici

dal,

show

If

posi

tive,

scr

een

with

PH

Q-9

, an

d ca

rry o

ut m

enta

l sta

tus

exam

inat

ion

N/A

Ye

s Ye

s

If

PH

Q-9

neg

ativ

e, re

scre

en

annu

ally

N/A

Ye

s Ye

s

If

PH

Q-9

pos

itive

car

ry o

ut fu

ll m

edic

al p

rofil

e (if

no

othe

r cau

se

dete

cted

, tre

atm

ent

shou

ld b

e in

itiat

ed b

y th

e pr

imar

y ca

re

phys

icia

n; c

ompl

ex c

ases

sh

ould

be

refe

rred

to a

S

peci

alis

t Clin

ic).

Follo

w u

p

CH

AP

TER

3:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DE

PR

ES

SIO

N

Dat

e Is

sued

: (

)Rev

ised

( )

New

P

age

3-5

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

Dep

ress

ion

Stag

e ac

ross

th

e Li

fe C

ours

e

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

base

d on

pla

n of

car

e fro

m th

e sp

ecia

list.

inad

equa

te re

spon

se to

mul

tiple

tre

atm

ents

, and

thos

e pr

esen

ting

with

psy

chot

ic s

ympt

oms.

H

igh

Ris

k:

S

cree

n tw

ice

year

ly w

ith P

HQ

-2

If

PH

Q-2

neg

ativ

e, re

peat

in 6

m

onth

s

Yes

Yes

Yes

If

PH

Q-2

pos

itive

, scr

een

with

P

HQ

-9

N/A

Ye

s Ye

s

If

PH

Q-9

neg

ativ

e, s

cree

n in

6

mon

ths

N/A

Ye

s Ye

s

If

PH

Q-9

pos

itive

, car

ry o

ut fu

ll m

edic

al p

rofil

e (if

no

othe

r cau

se

dete

cted

, tre

atm

ent s

houl

d be

in

itiat

ed b

y th

e pr

imar

y ca

re

phys

icia

n; c

ompl

ex c

ases

sh

ould

be

refe

rred

to a

S

peci

alis

t Clin

ic).

Follo

w u

p ba

sed

on p

lan

of c

are

from

the

spec

ialis

t.

N/A

Ye

s Ye

s

3.4

Preg

nant

/ Po

st-P

artu

m

Fem

ales

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on M

enta

l Hea

lth a

nd

Dep

ress

ion

(sig

ns &

sym

ptom

s,

risk

fact

ors,

scr

eeni

ng)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t w

orkp

lace

s, c

lubs

, rel

igio

us g

roup

s et

c., w

ithin

the

com

mun

ity.

E

duca

tion

on s

trate

gies

to

mai

ntai

n go

od m

enta

l hea

lth

Yes

Ye

s Ye

s

CH

AP

TER

3:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DE

PR

ES

SIO

N

Dat

e Is

sued

: (

)Rev

ised

( )

New

P

age

3-6

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

Dep

ress

ion

Stag

e ac

ross

th

e Li

fe C

ours

e

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

Scr

eeni

ng s

houl

d be

don

e at

ea

ch a

nten

atal

and

pos

tnat

al

visi

t with

PH

Q-2

N/A

Ye

s Ye

s

If

PH

Q-2

neg

ativ

e, re

peat

at

subs

eque

nt v

isit

N/A

Ye

s Ye

s

If

PH

Q-2

pos

itive

, scr

een

with

P

HQ

-9

N/A

Ye

s Ye

s

If

PH

Q-9

neg

ativ

e, re

peat

sc

reen

with

in 3

mon

ths

N/A

Ye

s Ye

s

If

PH

Q-9

pos

itive

car

ry o

ut fu

ll m

edic

al p

rofil

e (if

no

othe

r cau

se

dete

cted

, tre

atm

ent

shou

ld b

e in

itiat

ed b

y th

e pr

imar

y ca

re

phys

icia

n; c

ompl

ex c

ases

sh

ould

be

refe

rred

to a

S

peci

alis

t Clin

ic).

Follo

w u

p ba

sed

on p

lan

of c

are

from

the

spec

ialis

t.

N/A

Ye

s Ye

s

3.5

Late

A

dulth

ood

(Eld

erly

)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on M

enta

l Hea

lth a

nd

Dep

ress

ion

(sig

ns &

sym

ptom

s,

risk

fact

ors,

scr

eeni

ng)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t w

orkp

lace

s, c

lubs

, rel

igio

us g

roup

s et

c., w

ithin

the

com

mun

ity.

E

duca

tion

on s

trate

gies

to

mai

ntai

n go

od m

enta

l hea

lth

Yes

Yes

Yes

CH

AP

TER

3:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DE

PR

ES

SIO

N

Dat

e Is

sued

: (

)Rev

ised

( )

New

P

age

3-6

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

Dep

ress

ion

Stag

e ac

ross

th

e Li

fe C

ours

e

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

Scr

eeni

ng s

houl

d be

don

e at

ea

ch a

nten

atal

and

pos

tnat

al

visi

t with

PH

Q-2

N/A

Ye

s Ye

s

If

PH

Q-2

neg

ativ

e, re

peat

at

subs

eque

nt v

isit

N/A

Ye

s Ye

s

If

PH

Q-2

pos

itive

, scr

een

with

P

HQ

-9

N/A

Ye

s Ye

s

If

PH

Q-9

neg

ativ

e, re

peat

sc

reen

with

in 3

mon

ths

N/A

Ye

s Ye

s

If

PH

Q-9

pos

itive

car

ry o

ut fu

ll m

edic

al p

rofil

e (if

no

othe

r cau

se

dete

cted

, tre

atm

ent

shou

ld b

e in

itiat

ed b

y th

e pr

imar

y ca

re

phys

icia

n; c

ompl

ex c

ases

sh

ould

be

refe

rred

to a

S

peci

alis

t Clin

ic).

Follo

w u

p ba

sed

on p

lan

of c

are

from

the

spec

ialis

t.

N/A

Ye

s Ye

s

3.5

Late

A

dulth

ood

(Eld

erly

)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on M

enta

l Hea

lth a

nd

Dep

ress

ion

(sig

ns &

sym

ptom

s,

risk

fact

ors,

scr

eeni

ng)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t w

orkp

lace

s, c

lubs

, rel

igio

us g

roup

s et

c., w

ithin

the

com

mun

ity.

E

duca

tion

on s

trate

gies

to

mai

ntai

n go

od m

enta

l hea

lth

Yes

Yes

Yes

CH

AP

TER

3:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DE

PR

ES

SIO

N

Dat

e Is

sued

: (

)Rev

ised

( )

New

P

age

3-7

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

Dep

ress

ion

Stag

e ac

ross

th

e Li

fe C

ours

e

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

Scr

een

2-4

times

yea

rly w

ith

PH

Q-2

(bas

ed o

n cl

inic

al

asse

ssm

ent o

f ris

k)

If

PH

Q-2

neg

ativ

e, re

peat

in 6

m

onth

s

N/A

Ye

s Ye

s A

vera

ge ri

sk p

atie

nts

can

be

scre

ened

twic

e ye

arly

. H

igh

risk

patie

nts

shou

ld b

e sc

reen

ed 4

tim

es y

early

.

If P

HQ

-2 p

ositi

ve, s

cree

n w

ith

PH

Q-9

N

/A

Yes

Yes

If

PH

Q-9

neg

ativ

e, s

cree

n in

3-

4 m

onth

s N

/A

Yes

Yes

If

PH

Q-9

pos

itive

, car

ry o

ut fu

ll m

edic

al p

rofil

e (if

no

othe

r cau

se

dete

cted

, tre

atm

ent s

houl

d be

in

itiat

ed b

y th

e pr

imar

y ca

re

phys

icia

n; c

ompl

ex c

ases

sh

ould

be

refe

rred

to a

S

peci

alis

t Clin

ic).

Follo

w u

p ba

sed

on p

lan

of c

are

from

the

spec

ialis

t.

N/A

Ye

s Ye

s

CH

AP

TER

3:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

EP

RE

SSIO

N

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 3-

8

Fi

gure

5: A

lgor

ithm

for S

cree

ning

Ref

erra

l and

Fol

low

Up

in A

dole

scen

ts a

t Ave

rage

and

Hig

h R

isk

for M

ajor

D

epre

ssio

n A

bbre

viat

ions

: MH

T, M

enta

l Hea

lth T

eam

; PH

C, p

rimar

y he

alth

car

e; -v

e, K

AD

S-6

neg

ativ

e =

scor

e<6;

+ve

, KA

DS

-6 p

ositi

ve =

sco

re 6

or >

*

Ado

lesc

ents

at h

igh

risk

shou

ld b

e sc

reen

ed a

t lea

st a

nnua

lly

Sche

dule

d re

scre

en p

ost t

reat

men

tby

chi

ld g

uida

nce

serv

ices

Hig

h R

isk:

P

erso

nal/

fam

ily

hist

ory

of m

enta

l he

alth

dis

orde

r, st

ate

care

, his

tory

of

chr

onic

illn

ess,

tra

umat

ic li

fe e

vent

, si

ngle

par

ent h

ome,

se

xual

min

oriti

es,

subs

tanc

e ab

use

Aver

age

Ris

k:D

ual-p

aren

t hom

e,

good

soc

ioec

onom

ic

back

grou

nd, g

ood

fam

ily s

uppo

rt

Res

cree

n on

ce y

early

(low

risk

gr

oup)

3 tim

es y

early

(hig

h-ris

k gr

oup)

*

Full

med

ical

pr

ofile

&

need

for

furt

her

diag

nosi

s by

PH

C

team

Men

tal h

ealth

as

sess

men

t an

d Tr

eatm

ent

in c

hild

gu

idan

ce

spec

ialis

t se

rvic

es in

M

HT

+ve

-ve

refe

r

Asy

mpt

omat

ic11

-19

year

s

follo

w u

p

KA

DS-

6

CH

APT

ER 3

:

SCR

EEN

ING

GU

IDEL

INES

FO

R

DEP

RE

SSIO

N

Dat

e Is

sued

: (

) R

evis

ed

( )

New

Pa

ge 3

-9

Figu

re 6

: Alg

orith

m fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w U

p in

Adu

lts a

t Ave

rage

Ris

k an

d H

igh

Ris

k fo

r Maj

or

Dep

ress

ion

Abb

revi

atio

ns: P

HQ

-2, P

atie

nt H

ealth

Que

stio

nnai

re 2

; PH

Q-2

+ve

, pos

itive

= y

es to

eith

er q

uest

ion;

PH

Q-2

-ve,

neg

ativ

e =

no to

bot

h qu

estio

ns;

PH

Q-9

+ve

, pos

itive

= s

core

5 o

r >5;

PH

Q-9

-ve,

neg

ativ

e =

<5; P

HC

, prim

ary

heal

th c

are;

MH

T, M

enta

l Hea

lth T

eam

; *C

riter

ia fo

r ref

erra

l to

the

MH

T is

in th

e m

hGA

P fo

r man

agem

ent o

f com

mon

men

tal h

ealth

dis

orde

rs in

prim

ary

care

. **

Res

cree

n: H

igh

Ris

k G

roup

s, tw

ice

annu

ally

; Ave

rage

Ris

k G

roup

s, a

nnua

lly; T

he E

lder

ly, 2

-4 ti

mes

per

yea

r; P

regn

ant &

Pos

t-par

tum

, eac

h an

tena

tal &

pos

tnat

al v

isit

Spec

ialis

t Clin

icM

HT

Hig

h R

isk:

Fe

mal

e, p

erso

nal/

fam

ily h

isto

ry o

f m

enta

l hea

lth d

isor

der;

poor

soc

ioec

onom

ic

back

grou

nd; h

isto

ry

of c

hron

ic il

lnes

s;

disa

bilit

ies;

neg

ativ

e lif

e ev

ent;

sing

le p

aren

t; se

xual

min

oriti

es;

subs

tanc

e ab

use;

an

tena

tal a

nd p

ostn

atal

w

omen

Aver

age

Ris

k:M

ale;

goo

d so

cioe

cono

mic

ba

ckgr

ound

; goo

d fa

mily

/ frie

nd s

uppo

rt;

mar

ried;

em

ploy

ed

**R

escr

een

at 4

-12

mon

ths

base

d on

Ris

k A

sses

smen

t

PHQ

-9Fu

ll m

edic

al

profi

le &

m

enta

l he

alth

as

sess

men

t fo

r dia

gnos

is

PHC

*

+ve

+ve

-ve

refe

r

≥20

year

s

follo

w u

p

Ref

er c

ompl

ex

case

s PH

Q-2

Trea

tmen

t st

arte

d at

PH

C

S

UB

JEC

T: S

CR

EE

NIN

G G

UID

ELI

NE

S FO

R P

RIO

RIT

Y N

CD

s

P

AGE

4-1

C

hapt

er 4

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TYP

E 2

D

ATE

ISS

UE

D:

( )

Rev

ised

( )

New

4.1

Ris

k G

roup

s an

d Sp

ecia

l Con

side

ratio

ns fo

r the

Scr

eeni

ng o

f Dia

bete

s M

ellit

us (D

M) T

ype

2

Life

Cou

rse

Stag

e R

isk

Gro

up

Def

initi

on o

f the

Gro

up

Ado

lesc

ence

A

vera

ge R

isk

Gro

up

Chi

ldre

n an

d ad

oles

cent

s w

ithou

t sym

ptom

s (a

sym

ptom

atic

) of

Dia

bete

s M

ellit

us a

nd w

ithou

t ris

k fa

ctor

s

Hig

h R

isk

Gro

up

Chi

ldre

n an

d ad

oles

cent

s w

ithou

t sym

ptom

s (a

sym

ptom

atic

) of

Dia

bete

s M

ellit

us w

ith ri

sk fa

ctor

s:

Ele

vate

d bo

dy m

ass

inde

x. S

cree

ning

wou

ld b

e w

ithin

the

scho

ol

med

ical

und

erta

ken

for a

ll en

trant

s to

sec

onda

ry s

choo

ls a

nd fo

r all

over

wei

ght a

nd o

bese

chi

ldre

n an

d ad

oles

cent

s w

ho fu

lfil t

he c

riter

ia

for s

cree

ning

for d

iabe

tes:

Cla

ssifi

catio

n of

hig

h-ris

k ch

ild/a

dole

scen

t:

Obe

se –

BM

I-for

-age

z-s

core

>2

usin

g W

HO

Chi

ld G

row

th

Sta

ndar

ds

Ove

rwei

ght –

BM

I-for

-age

z-s

core

>1

to 2

usi

ng W

HO

Chi

ld

Gro

wth

Sta

ndar

ds

Plu

s, tw

o or

mor

e ad

ditio

nal r

isk

fact

ors:

Fa

mily

his

tory

of t

ype

2 di

abet

es in

firs

t deg

ree

and

seco

nd

degr

ee re

lativ

e

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DIA

BET

ES

ME

LLIT

US

TYP

E 2

D

ate

Issu

ed:

( )

Rev

ised

(

)

New

P

age

4-2

Li

fe C

ours

e St

age

Ris

k G

roup

D

efin

ition

of t

he G

roup

S

igns

of i

nsul

in re

sist

ance

or c

ondi

tions

ass

ocia

ted

with

insu

lin

resi

stan

ce (a

cant

hosi

s ni

gric

ans,

hyp

erte

nsio

n, d

yslip

idae

mia

, po

lycy

stic

ova

ry s

yndr

ome,

or s

mal

l-for

-ges

tatio

nal-a

ge b

irth

wei

ght)

M

ater

nal h

isto

ry o

f dia

bete

s or

Ges

tatio

nal D

iabe

tes

(for t

he

child

's g

esta

tion)

Adu

lthoo

d A

vera

ge R

isk

Gro

up

Adu

lts w

ith n

o ris

k fa

ctor

s sh

ould

sta

rt s

cree

ning

at 4

5y (2

0)

Hig

h R

isk

Gro

up

Adu

lts ≥

30y

with

risk

fact

ors:

Ove

rwei

ght o

r obe

se (B

MI >

25 k

g/m

2 ) a

nd a

mon

g ad

ults

who

hav

e on

e or

mor

e of

the

follo

win

g ris

k fa

ctor

s:

Firs

t-deg

ree

rela

tive

with

dia

bete

s

H

isto

ry o

f Car

diov

ascu

lar D

isea

se (C

VD

)

H

yper

tens

ion

(BP≥1

40/9

0 m

mH

g or

on

ther

apy

for

hype

rtens

ion)

H

DL

chol

este

rol l

evel

, <0.

90 m

mol

/L (3

5 m

g/dL

) and

/or a

tri

glyc

erid

e le

vel >

2.82

mm

ol/L

(250

mg/

dL)

Wom

en w

ith p

olyc

ystic

ova

ry s

yndr

ome

Phy

sica

l ina

ctiv

ity

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R

DIA

BET

ES

ME

LLIT

US

TYP

E 2

D

ate

Issu

ed:

( )

Rev

ised

(

)

New

P

age

4-3

Li

fe C

ours

e St

age

Ris

k G

roup

D

efin

ition

of t

he G

roup

O

ther

clin

ical

con

ditio

ns a

ssoc

iate

d w

ith in

sulin

resi

stan

ce

(e.g

., se

vere

obe

sity

, aca

ntho

sis

nigr

ican

s)

Adu

lt Fe

mal

e in

Pr

egna

ncy

Ave

rage

Ris

k G

roup

A

sym

ptom

atic

ant

enat

al w

ith lo

w ri

sk o

f DM

.

Hig

h R

isk

Gro

up

Asy

mpt

omat

ic a

nten

atal

with

hig

h ris

k of

DM

.

Ris

k fa

ctor

s th

at in

crea

se a

wom

an's

risk

for d

evel

opin

g G

esta

tiona

l D

iabe

tes

Mel

litus

(GD

M) i

nclu

des:

O

besi

ty

Incr

ease

d m

ater

nal a

ge (≥

35)

His

tory

of G

DM

W

omen

with

a h

isto

ry o

f mac

roso

mia

Fa

mily

his

tory

of d

iabe

tes

Late

Adu

lthoo

d (E

lder

ly)

Ave

rage

Ris

k A

dults

≥60

y w

ith n

o ris

k fa

ctor

s

Hig

h R

isk

Sam

e as

gen

eral

adu

lt po

pula

tion

(20)

(21)

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

4

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

DIA

BET

ES M

ELIT

US

TYPE

2

Stag

e ac

ross

the

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

4.2

Chi

ldho

od &

A

dole

scen

ce

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on ri

sk fa

ctor

s of

D

iabe

tes

Mel

litus

in

adol

esce

nts

and

child

ren

with

focu

s on

life

styl

e ch

ange

s su

ch a

s nu

tritio

n,

exer

cise

and

sed

enta

ry

lifes

tyle

s

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

, with

in

the

com

mun

ity.

O

pera

tiona

l pol

icy

actio

n pl

an to

redu

ce p

reva

lenc

e of

ov

erw

eigh

t and

obe

sity

am

ong

the

paed

iatri

c po

pula

tion

N/A

Ye

s Ye

s

P

rom

ote

Jam

aica

Mov

es

Pro

gram

me

(or o

ther

sim

ilar

heal

thy

lifes

tyle

pro

gram

me)

at

the

com

mun

ity le

vel a

nd in

sc

hool

s

Yes

N/A

N

/A

Sch

ool h

ealth

pro

gram

mes

are

a

favo

urab

le e

ntry

poi

nt fo

r tes

ting

for

wha

t will

be

mos

tly a

n in

-sch

ool

popu

latio

n (s

choo

l med

ical

)

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

4

NO

N-C

OM

MU

NIC

AB

LE D

ISEA

SES

DIA

BET

ES M

ELIT

US

TYPE

2

Stag

e ac

ross

the

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

4.2

Chi

ldho

od &

A

dole

scen

ce

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on ri

sk fa

ctor

s of

D

iabe

tes

Mel

litus

in

adol

esce

nts

and

child

ren

with

focu

s on

life

styl

e ch

ange

s su

ch a

s nu

tritio

n,

exer

cise

and

sed

enta

ry

lifes

tyle

s

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

, with

in

the

com

mun

ity.

O

pera

tiona

l pol

icy

actio

n pl

an to

redu

ce p

reva

lenc

e of

ov

erw

eigh

t and

obe

sity

am

ong

the

paed

iatri

c po

pula

tion

N/A

Ye

s Ye

s

P

rom

ote

Jam

aica

Mov

es

Pro

gram

me

(or o

ther

sim

ilar

heal

thy

lifes

tyle

pro

gram

me)

at

the

com

mun

ity le

vel a

nd in

sc

hool

s

Yes

N/A

N

/A

Sch

ool h

ealth

pro

gram

mes

are

a

favo

urab

le e

ntry

poi

nt fo

r tes

ting

for

wha

t will

be

mos

tly a

n in

-sch

ool

popu

latio

n (s

choo

l med

ical

)

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

5

Scre

enin

g &

Ear

ly D

iagn

osis

Ave

rage

Ris

k:

C

hild

ren

and

adol

esce

nts

with

out s

ympt

oms

of

Dia

bete

s M

ellit

us w

ithou

t ris

k fa

ctor

s ar

e no

t scr

eene

d fo

r di

abet

es

N/A

N

/A

N/A

Hig

h R

isk:

S

cree

n w

ith F

astin

g B

lood

G

luco

se (F

BG

) and

Ora

l G

luco

se T

oler

ance

Tes

t (O

GTT

2hr

Pos

t Pra

ndia

l)

Yes

Yes

Yes

If po

sitiv

e en

cour

age

lifes

tyle

ch

ange

s; fu

ll m

edic

al p

rofil

e sh

ould

be

don

e an

d re

scre

en in

3 m

onth

s.

Trea

tmen

t sho

uld

be s

tarte

d an

d re

ferra

l to

a Sp

ecia

list (

paed

iatri

c or

en

docr

inol

ogy)

Clin

ic. (

*see

di

abet

es m

anag

emen

t gui

delin

es

for r

efer

ral c

riter

ia)

If

nega

tive

resc

reen

eve

ry 2

ye

ars.

Ye

s Ye

s Ye

s

4.3

Adul

thoo

d an

d La

te

Adu

lthoo

d

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on ri

sk fa

ctor

s of

D

iabe

tes

Mel

litus

in th

e ad

ult

popu

latio

n w

ith fo

cus

on

lifes

tyle

cha

nges

suc

h as

nu

tritio

n, e

xerc

ise

and

sede

ntar

y lif

esty

les

Yes

Yes

Yes

O

pera

tiona

l pol

icy

actio

n pl

an to

redu

ce p

reva

lenc

e of

N

/A

N/A

N

/A

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

6

over

wei

ght a

nd o

besi

ty

amon

g th

e ad

ult p

opul

atio

n.

Scre

enin

g &

Ear

ly D

iagn

osis

Ave

rage

Ris

k:

S

cree

ning

sho

uld

star

t at a

ge

≥45

year

s ol

d w

ith F

BG

and

O

GTT

Yes

Yes

Yes

If ei

ther

FB

G o

r OG

TT is

pos

itive

, it

shou

ld b

e re

peat

ed. A

full

med

ical

pr

ofile

sho

uld

then

be

done

, and

tre

atm

ent s

houl

d be

sta

rted

with

re

ferra

l to

a Sp

ecia

list C

linic

whe

n re

quire

d (*

see

diab

etes

m

anag

emen

t gui

delin

es fo

r re

ferr

al c

riter

ia)

If

nega

tive,

res

cree

n ev

ery

2 ye

ars

Hig

h R

isk:

S

cree

ning

sho

uld

star

t at a

ge

≥ 30

yea

rs o

ld w

ith F

BG

and

O

GTT

Yes

Yes

Yes

Pat

ient

s th

at te

st p

ositi

ve s

houl

d al

so b

e sc

reen

ed fo

r hyp

erte

nsio

n an

d lin

ked

to p

reve

ntat

ive

serv

ices

.

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

6

over

wei

ght a

nd o

besi

ty

amon

g th

e ad

ult p

opul

atio

n.

Scre

enin

g &

Ear

ly D

iagn

osis

Ave

rage

Ris

k:

S

cree

ning

sho

uld

star

t at a

ge

≥45

year

s ol

d w

ith F

BG

and

O

GTT

Yes

Yes

Yes

If ei

ther

FB

G o

r OG

TT is

pos

itive

, it

shou

ld b

e re

peat

ed. A

full

med

ical

pr

ofile

sho

uld

then

be

done

, and

tre

atm

ent s

houl

d be

sta

rted

with

re

ferra

l to

a Sp

ecia

list C

linic

whe

n re

quire

d (*

see

diab

etes

m

anag

emen

t gui

delin

es fo

r re

ferr

al c

riter

ia)

If

nega

tive,

res

cree

n ev

ery

2 ye

ars

Hig

h R

isk:

S

cree

ning

sho

uld

star

t at a

ge

≥ 30

yea

rs o

ld w

ith F

BG

and

O

GTT

Yes

Yes

Yes

Pat

ient

s th

at te

st p

ositi

ve s

houl

d al

so b

e sc

reen

ed fo

r hyp

erte

nsio

n an

d lin

ked

to p

reve

ntat

ive

serv

ices

.

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

7

If

nega

tive,

resc

reen

an

nual

ly fo

r all

high

-risk

ad

ults

.

Yes

Yes

Yes

If po

sitiv

e, re

peat

FB

G a

nd O

GTT

. If

eith

er p

ositi

ve, a

full

med

ical

pr

ofile

sho

uld

be d

one.

Tre

atm

ent

shou

ld b

e st

arte

d w

ith re

ferra

l to

a S

peci

alis

t Clin

ic w

hen

requ

ired

(*se

e di

abet

es m

anag

emen

t gu

idel

ines

for r

efer

ral c

riter

ia).

4.4

Adul

t Fem

ale

durin

g Pr

egna

ncy

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on d

iet,

exer

cise

, sm

okin

g an

d al

coho

l use

Ye

s Ye

s Ye

s

E

duca

te o

n ea

rly a

dmis

sion

in

to a

nten

atal

clin

ic (b

efor

e 12

wee

ks) a

nd c

ontin

uous

at

tend

ance

Yes

Yes

Yes

E

duca

te o

n D

iabe

tes

in

preg

nanc

y an

d su

bseq

uent

fo

llow

-up

in p

ost-p

artu

m.

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

Ave

rage

Ris

k:

S

cree

ning

at 2

4 w

eeks

ge

stat

ion

with

O’S

ulliv

an's

Te

st; C

ardi

ovas

cula

r Dis

ease

(C

VD

) ris

k as

sess

men

t sh

ould

als

o be

don

e an

d re

ferra

l for

furth

er c

are

as

indi

cate

d.

N/A

Ye

s Ye

s If

O’S

ulliv

an’s

test

is p

ositi

ve a

t 24

wee

ks a

nten

atal

vis

it th

e pa

tient

, th

en, s

houl

d be

furth

er s

cree

ned

with

OG

TT.

If O

GTT

is p

ositi

ve, r

efer

to a

n O

bste

tric

Spec

ialis

t (hi

gh-ri

sk)

Clin

ic

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

8

If

O’S

ulliv

an is

neg

ativ

e at

24

wee

ks, r

escr

een

at 2

8 w

eeks

.

N/A

Ye

s Ye

s If

OG

TT is

neg

ativ

e pa

tient

sho

uld

be re

scre

ened

at 2

8 w

eeks

with

O

’Sul

livan

test

(s

ee d

iabe

tes

man

agem

ent

guid

elin

es fo

r ref

erra

l crit

eria

).

If

O’S

ulliv

an is

neg

ativ

e at

24

wee

ks, r

escr

een

at 2

8 w

eeks

.

N/A

Ye

s Ye

s

Hig

h R

isk:

Scr

eeni

ng a

t firs

t ant

enat

al

visi

t with

O’S

ulliv

an’s

Tes

t is

indi

cate

d; C

VD

risk

as

sess

men

t sho

uld

also

be

done

as

indi

cate

d (2

2)

N/A

Ye

s Ye

s If

O’S

ulliv

an’s

test

is p

ositi

ve a

t firs

t an

tena

tal v

isit,

the

patie

nt th

en

shou

ld b

e fu

rther

scr

eene

d w

ith

OG

TT.

If O

GTT

is p

ositi

ve a

t firs

t ant

enat

al

visi

t, re

fer t

o an

Obs

tetri

c S

peci

alis

t (h

igh-

risk)

Clin

ic fo

r con

tinue

d m

anag

emen

t. If

test

is n

egat

ive,

pat

ient

sho

uld

be

resc

reen

ed a

t 24

wee

ks g

esta

tion.

If

O’S

ulliv

an’s

Tes

t is

posi

tive

at 2

4 w

eeks

ges

tatio

n, th

e pa

tient

then

sh

ould

be

furth

er s

cree

ned

with

O

GTT

. If

OG

TT is

pos

itive

, ref

er to

an

Obs

tetri

c S

peci

alis

t (hi

gh-ri

sk)

Clin

ic fo

r con

tinue

d m

anag

emen

t.

If O

’Sul

livan

’s T

est i

s ne

gativ

e at

firs

t ant

enat

al

visi

t, re

scre

en a

t 24

wee

ks

gest

atio

n.

N/A

Ye

s Ye

s

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

8

If

O’S

ulliv

an is

neg

ativ

e at

24

wee

ks, r

escr

een

at 2

8 w

eeks

.

N/A

Ye

s Ye

s If

OG

TT is

neg

ativ

e pa

tient

sho

uld

be re

scre

ened

at 2

8 w

eeks

with

O

’Sul

livan

test

(s

ee d

iabe

tes

man

agem

ent

guid

elin

es fo

r ref

erra

l crit

eria

).

If

O’S

ulliv

an is

neg

ativ

e at

24

wee

ks, r

escr

een

at 2

8 w

eeks

.

N/A

Ye

s Ye

s

Hig

h R

isk:

Scr

eeni

ng a

t firs

t ant

enat

al

visi

t with

O’S

ulliv

an’s

Tes

t is

indi

cate

d; C

VD

risk

as

sess

men

t sho

uld

also

be

done

as

indi

cate

d (2

2)

N/A

Ye

s Ye

s If

O’S

ulliv

an’s

test

is p

ositi

ve a

t firs

t an

tena

tal v

isit,

the

patie

nt th

en

shou

ld b

e fu

rther

scr

eene

d w

ith

OG

TT.

If O

GTT

is p

ositi

ve a

t firs

t ant

enat

al

visi

t, re

fer t

o an

Obs

tetri

c S

peci

alis

t (h

igh-

risk)

Clin

ic fo

r con

tinue

d m

anag

emen

t. If

test

is n

egat

ive,

pat

ient

sho

uld

be

resc

reen

ed a

t 24

wee

ks g

esta

tion.

If

O’S

ulliv

an’s

Tes

t is

posi

tive

at 2

4 w

eeks

ges

tatio

n, th

e pa

tient

then

sh

ould

be

furth

er s

cree

ned

with

O

GTT

. If

OG

TT is

pos

itive

, ref

er to

an

Obs

tetri

c S

peci

alis

t (hi

gh-ri

sk)

Clin

ic fo

r con

tinue

d m

anag

emen

t.

If O

’Sul

livan

’s T

est i

s ne

gativ

e at

firs

t ant

enat

al

visi

t, re

scre

en a

t 24

wee

ks

gest

atio

n.

N/A

Ye

s Ye

s

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

9

Fi

gure

7: A

lgor

ithm

, for

Scr

eeni

ng R

efer

ral a

nd F

ollo

w-u

p in

Chi

ldre

n an

d Ad

oles

cent

s at

Hig

h R

isk

for D

iabe

tes

Mel

litus

Typ

e 2

Abb

revi

atio

ns: F

MP-

DM

2, F

ull m

edic

al p

rofil

e fo

r Dia

bete

s M

ellit

us T

ype

2; P

HC

, prim

ary

heal

th c

are;

-ve,

neg

ativ

e (F

astin

g B

lood

Glu

cose

or

Ora

l Glu

cose

Tol

eran

ce T

est n

orm

al);

+ve,

pos

itive

(ele

vate

d Fa

stin

g B

lood

Glu

cose

or O

ral G

luco

se T

oler

ance

Tes

t *1 P

lus

2 or

mor

e ris

k fa

ctor

s *2 S

ee c

linic

al m

anag

emen

t gui

delin

e

Hig

h R

isk:

E

leva

ted

body

mas

s in

dex,

ove

rwei

ght

and

obes

e ch

ildre

n (≥

10)

and

adol

esce

nts

(<18

) who

fulfi

l the

crit

eria

fo

r scr

eeni

ng fo

r dia

bete

s:

Cla

ssifi

catio

n of

hig

h-ris

k ch

ild/a

dole

scen

t: O

verw

eigh

t/Obe

se (B

MI >

1 z-

scor

e fo

r ag

e an

d se

x)

Plu

s,

two

or

mor

e ad

ditio

nal

risk

fact

ors:

Fa

mily

his

tory

of t

ype

2 di

abet

es in

firs

t de

gree

and

sec

ond

degr

ee r

elat

ive;

si

gns

of in

sulin

resi

stan

ce o

r con

ditio

ns

asso

ciat

ed w

ith in

sulin

resi

stan

ce

+FB

G, -

ve O

GTT

(2

hrPP

) & -v

e FM

P-D

M2:

resc

reen

in 3

m

onth

s in

PH

C

Res

cree

n ev

ery

2 ye

ar

Enco

urag

e lif

esty

le

chan

ges

FMP–

DM

2 do

ne in

PHC

*+v

e

+ve

-ve

Asy

mpt

omat

ic a

dole

scen

ts

and

child

ren

<20y

Ove

rwei

ght/o

bese

*1

FBG

& O

GTT

Trea

tmen

t sta

rted

by

PHC

with

refe

rral

to a

sp

ecia

list

clin

ic (p

aedi

-at

ric o

r end

ocrin

olog

y) *2

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

10

Fi

gure

8: A

lgor

ithm

s fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w-u

p in

Adu

lts a

t Ave

rage

Ris

k fo

r Typ

e 2

Dia

bete

s M

ellit

us

Abb

revi

atio

ns: P

HC

, prim

ary

heal

th c

are;

-ve,

neg

ativ

e (n

orm

al F

astin

g B

lood

Glu

cose

or O

ral G

luco

se T

oler

ance

Tes

t); +

ve, p

ositi

ve (e

leva

ted

Fast

ing

Blo

od G

luco

se o

r Ora

l Glu

cose

Tol

eran

ce T

est)

*C

riter

ia fo

r spe

cial

ist c

are

from

the

clin

ical

man

agem

ent g

uide

line

Ave

rage

Ris

k:

A

dults

with

no

risk

fact

ors

N

il pe

rson

al h

isto

ry

of D

M Tr

eatm

ent P

HC

w

ith re

ferr

al to

sp

ecia

list w

hen

requ

ired*

Res

cree

n:Ev

ery

2 ye

ars

if no

risk

fact

or

Full

med

ical

pr

ofile

in P

HC

Rep

eat

FBG

& O

GTT

Eith

er +

ve

Eith

er +

ve

Bot

h -v

e

Asy

mpt

omat

icAv

erag

e ris

k: N

o ris

k fa

ctor

, >4

5y

FBG

& O

GTT

* (7

5g g

luco

se)

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

10

Fi

gure

8: A

lgor

ithm

s fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w-u

p in

Adu

lts a

t Ave

rage

Ris

k fo

r Typ

e 2

Dia

bete

s M

ellit

us

Abb

revi

atio

ns: P

HC

, prim

ary

heal

th c

are;

-ve,

neg

ativ

e (n

orm

al F

astin

g B

lood

Glu

cose

or O

ral G

luco

se T

oler

ance

Tes

t); +

ve, p

ositi

ve (e

leva

ted

Fast

ing

Blo

od G

luco

se o

r Ora

l Glu

cose

Tol

eran

ce T

est)

*C

riter

ia fo

r spe

cial

ist c

are

from

the

clin

ical

man

agem

ent g

uide

line

Ave

rage

Ris

k:

A

dults

with

no

risk

fact

ors

N

il pe

rson

al h

isto

ry

of D

M

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

11

Fi

gure

9: A

lgor

ithm

s fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w-U

p in

Adu

lts a

t Hig

h R

isk

for D

iabe

tes

Mel

litus

Typ

e 2

A

bbre

viat

ions

: -v

e, n

egat

ive

(nor

mal

Fas

ting

Blo

od G

luco

se o

r Ora

l Glu

cose

Tol

eran

ce T

est);

+ve

, pos

itive

(ele

vate

d Fa

stin

g B

lood

Glu

cose

or

Ora

l Glu

cose

Tol

eran

ce T

est);

PH

C, p

rimar

y he

alth

car

e *C

riter

ia fo

r spe

cial

ist c

are

from

the

clin

ical

man

agem

ent g

uide

line

Hig

h R

isk:

O

verw

eigh

t or o

bese

(BM

I ≥25

kg/

m2 )

and

am

ong

adul

ts w

ho h

ave

one

or m

ore

of th

e fo

llow

ing

risk

fact

ors:

Firs

t-deg

ree

rela

tive

with

dia

bete

s

His

tory

of C

ardi

ovas

cula

r Dis

ease

(C

VD

)

Hyp

erte

nsio

n (B

P>1

40/9

0 m

mH

g or

on

ther

apy

for h

yper

tens

ion)

;

Hyp

erlip

idae

mia

Wom

en w

ith p

olyc

ystic

ova

ry

synd

rom

e

Phy

sica

l ina

ctiv

ity

O

ther

clin

ical

con

ditio

ns a

ssoc

iate

d w

ith in

sulin

resi

stan

ce (e

.g.,

seve

re

obes

ity, a

cant

hosi

s ni

gric

ans)

Trea

tmen

t PH

C

with

refe

rral

to

spec

ialis

t whe

n re

quire

d*

Res

cree

n:

A

t lea

st a

nnua

lly fo

r hi

gh ri

sk

Full

med

ical

pr

ofile

in P

HC

Rep

eat F

BG

&

OG

TT

Eith

er +

ve

Eith

er +

ve

Bot

h -v

e

Asy

mpt

omat

icH

igh

risk,

>30

yFB

G &

OG

TT *

(75g

glu

cose

)

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

12

Fi

gure

10:

Alg

orith

m fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w U

p in

Wom

en a

t Ave

rage

Ris

k fo

r Dia

bete

s in

Pre

gnan

cy

Abb

revi

atio

ns: O

ST

– O

’Sul

livan

’s T

est;

FBG

, Fas

ting

Blo

od G

luco

se; O

GTT

, Ora

l Glu

cose

Tol

eran

ce T

est;

-v

e, n

egat

ive

(nor

mal

O’ S

ulliv

an

Test

, Fas

ting

Blo

od G

luco

se o

r Ora

l Glu

cose

Tol

eran

ce T

est);

+ve

, pos

itive

(ele

vate

d O

’Sul

livan

, Fas

ting

Blo

od G

luco

se o

r Ora

l Glu

cose

To

lera

nce

Test

) *

Furth

er c

are

wou

ld n

eed

to b

e id

entif

ied

to m

anag

e C

VD

risk

Res

cree

n at

28

wee

ks

Scr

een

for

CVD

Ris

kR

efer

for f

urth

er

care

as

indi

cate

d *

Ref

er fo

r spe

cial

ist c

are

– hi

gh ri

sk c

linic

*O

GTT

+ve

+ve -v

e

+ve

FBG

,

-ve

OG

TT

Asy

mpt

omat

ic*

preg

nant

scr

een

at 2

4 w

eeks

ges

tatio

n*O

ST

Aver

age

Ris

k:

Asy

mpt

omat

ic a

nten

atal

w

ith lo

w ri

sk o

f DM

.

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

12

Fi

gure

10:

Alg

orith

m fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w U

p in

Wom

en a

t Ave

rage

Ris

k fo

r Dia

bete

s in

Pre

gnan

cy

Abb

revi

atio

ns: O

ST

– O

’Sul

livan

’s T

est;

FBG

, Fas

ting

Blo

od G

luco

se; O

GTT

, Ora

l Glu

cose

Tol

eran

ce T

est;

-v

e, n

egat

ive

(nor

mal

O’ S

ulliv

an

Test

, Fas

ting

Blo

od G

luco

se o

r Ora

l Glu

cose

Tol

eran

ce T

est);

+ve

, pos

itive

(ele

vate

d O

’Sul

livan

, Fas

ting

Blo

od G

luco

se o

r Ora

l Glu

cose

To

lera

nce

Test

) *

Furth

er c

are

wou

ld n

eed

to b

e id

entif

ied

to m

anag

e C

VD

risk

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 4-

13

Fi

gure

11:

Alg

orith

m fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w U

p in

Wom

en a

t Hig

h R

isk

for D

iabe

tes

in P

regn

ancy

A

bbre

viat

ions

: OS

T –

O’S

ulliv

an’s

Tes

t; FB

G, F

astin

g B

lood

Glu

cose

; OG

TT, O

ral G

luco

se T

oler

ance

Tes

t;

-ve,

neg

ativ

e (n

orm

al O

’ Sul

livan

Te

st, F

astin

g B

lood

Glu

cose

or O

ral G

luco

se T

oler

ance

Tes

t); +

ve, p

ositi

ve (e

leva

ted

O’S

ulliv

an, F

astin

g B

lood

Glu

cose

or O

ral G

luco

se

Tole

ranc

e Te

st)

* Fu

rther

car

e w

ould

nee

d to

be

iden

tifie

d to

man

age

CV

D ri

sk

Res

cree

n at

24

wee

ks

Ref

er fo

r fur

ther

car

e as

indi

cate

d *Ref

er fo

r spe

cial

ist c

are

– hi

gh ri

sk

clin

ic *

OG

TT+v

e+v

e

-ve

+ve

FBG

,

-ve

OG

TT

Asy

mpt

omat

ic*

scre

en a

t firs

t ant

enat

al v

isit

OST

Hig

h R

isk:

Asy

mpt

omat

ic a

nten

atal

w

ith h

igh

risk

of D

M

Ris

k fa

ctor

s th

at

incr

ease

a w

oman

’s ri

sk

for d

evel

opin

g G

DM

in

clud

es:

•O

besi

ty•

Incr

ease

d m

ater

nal a

ge

(≥35)

•H

isto

ry o

f GD

M•

Wom

en w

ith

a hi

stor

y of

m

acro

som

ia

•Fa

mily

his

tory

(c

lose

rela

tive)

of

diab

etes

.

Scr

een

for C

VD

Ris

k

+ve

CH

AP

TER

4:

SC

RE

EN

ING

GU

IDE

LIN

ES

FO

R D

IABE

TES

ME

LLIT

US

TY

PE

2

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Pag

e 5-

1

S

UB

JEC

T: S

CR

EE

NIN

G G

UID

ELI

NE

S FO

R P

RIO

RIT

Y N

CD

s

P

AG

E 5

-1

Cha

pter

5 S

CR

EE

NIN

G G

UID

ELI

NE

S F

OR

BR

EAS

T C

AN

CE

R

DA

TE IS

SU

ED

:

( )

Rev

ised

( )

New

5.1

Ris

k G

roup

s an

d Sp

ecia

l Con

side

ratio

ns in

Scr

eeni

ng fo

r Bre

ast C

ance

r

Indi

cato

r C

onsi

dera

tions

Ris

k As

sess

men

t In

crea

sing

age

is th

e m

ost i

mpo

rtant

risk

fact

or fo

r mos

t wom

en

Scre

enin

g Te

sts

Bre

ast s

elf-e

xam

inat

ions

(SB

E) a

nd c

linic

al b

reas

t exa

min

atio

ns (C

BE

) are

not

incl

uded

in

the

stan

dard

s fo

r bre

ast c

ance

r scr

eeni

ng. H

owev

er, r

outin

e m

onth

ly S

BE

are

en

cour

aged

; any

cha

nges

det

ecte

d sh

ould

trig

ger a

vis

it to

a h

ealth

car

e pr

ovid

er w

ho w

ill

cond

uct a

CB

E a

nd in

vest

igat

e as

nec

essa

ry.

Dig

ital o

r film

mam

mog

raph

y as

the

prim

ary

met

hod

for b

reas

t can

cer s

cree

ning

wou

ld b

e ba

sed

on a

vaila

bilit

y. C

onve

ntio

nal d

igita

l scr

eeni

ng m

amm

ogra

phy

has

abou

t the

sam

e di

agno

stic

acc

urac

y as

film

ove

rall,

alth

ough

dig

ital s

cree

ning

see

ms

to h

ave

com

para

tivel

y hi

gher

sen

sitiv

ity b

ut th

e sa

me

or lo

wer

spe

cific

ity in

wom

en a

ge <

50 y

ears

.

Star

ting

and

Stop

ping

A

ges

for w

omen

who

are

at

ave

rage

risk

for b

reas

t ca

ncer

Mos

t of t

he b

enef

it of

mam

mog

raph

y re

sults

from

bie

nnia

l scr

eeni

ng d

urin

g ag

es 5

0 to

69

year

s. In

wom

en a

ged

40 to

49

year

s, w

hile

at r

isk

for b

reas

t can

cer d

eath

, the

num

ber o

f de

aths

ave

rted

is s

mal

ler t

han

that

in o

lder

wom

en a

nd th

e nu

mbe

r of f

alse

-pos

itive

re

sults

and

unn

eces

sary

bio

psie

s is

larg

er. T

he b

alan

ce o

f ben

efits

and

har

ms

is li

kely

to

impr

ove

as w

omen

mov

e fro

m th

eir e

arly

to la

te 4

0s.

Scre

enin

g in

w

omen

at h

ighe

r ris

k fo

r bre

ast

canc

er

Wom

en a

t hig

her r

isk

are

defin

ed a

s su

ch b

ased

on:

Fa

mily

his

tory

CH

APT

ER 5

SCR

EEN

ING

GU

IDEL

INE

FO

R B

RE

AST

CAN

CE

R

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Page

5-2

P

rior d

iagn

osis

of b

reas

t can

cer

C

hest

radi

atio

n

G

enet

ical

ly te

sted

(BR

CA

1 o

r 2 m

utat

ion

(17)

and

oth

er m

utat

ions

incl

udin

g TP

3 (2

5) –

test

ing

is n

ot in

dica

ted

in th

e pr

imar

y ca

re s

ettin

g

Ris

k as

sess

men

t and

scr

eeni

ng s

houl

d be

don

e in

the

prim

ary

heal

th c

are

setti

ng. A

re

ferra

l sho

uld

then

be

mad

e to

a S

peci

alis

t Clin

ic fo

r fur

ther

man

agem

ent.

Scr

eeni

ng fo

r wom

en w

ith h

igh

risk

is d

one

in a

Spe

cial

ist C

linic

; scr

eeni

ng te

sts

can

be

requ

este

d in

prim

ary

care

but

sho

uld

not d

elay

refe

rral t

o a

Spec

ialis

t Clin

ic .

The

scre

enin

g re

com

men

datio

n fo

r wom

en w

ith h

igh

risk

is M

RI a

djun

ct to

Mam

mog

raph

y.

The

frequ

ency

is d

eter

min

ed b

y th

e le

vel o

f ris

k an

d sh

ould

be

dete

rmin

ed b

y th

e sp

ecia

list.

If po

sitiv

e, re

ferra

l for

trea

tmen

t sho

uld

be m

ade

by th

e sp

ecia

list.

If ne

gativ

e,

scre

enin

g sh

ould

be

cont

inue

d as

det

erm

ined

by

the

spec

ialis

t.

Scre

enin

g in

Men

M

en m

ay d

evel

op b

reas

t can

cer a

nd s

houl

d be

enc

oura

ged

to fe

el th

eir b

reas

t and

che

st

wal

l and

repo

rt to

thei

r doc

tor a

ny lu

mps

or c

hang

e. M

en w

ho h

ave

a B

RC

A1

and

BR

CA

2 ge

ne m

utat

ion,

men

who

hav

e el

evat

ed le

vels

of o

estro

gen

due

to c

erta

in c

ondi

tions

suc

h as

live

r dis

ease

, and

men

on

drug

trea

tmen

t for

pro

stat

e ca

ncer

are

at i

ncre

ased

risk

for

brea

st c

ance

r. O

ther

risk

fact

ors

incl

ude

obes

ity.

Doc

tor m

ay re

com

men

d sc

reen

ing

with

m

amm

ogra

phy

for t

hose

men

who

with

a B

RC

A2

BR

CA

1 m

utat

ion

(23)

.

CH

APT

ER 5

SCR

EEN

ING

GU

IDEL

INE

FO

R B

RE

AST

CAN

CE

R

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Page

5-2

P

rior d

iagn

osis

of b

reas

t can

cer

C

hest

radi

atio

n

G

enet

ical

ly te

sted

(BR

CA

1 o

r 2 m

utat

ion

(17)

and

oth

er m

utat

ions

incl

udin

g TP

3 (2

5) –

test

ing

is n

ot in

dica

ted

in th

e pr

imar

y ca

re s

ettin

g

Ris

k as

sess

men

t and

scr

eeni

ng s

houl

d be

don

e in

the

prim

ary

heal

th c

are

setti

ng. A

re

ferra

l sho

uld

then

be

mad

e to

a S

peci

alis

t Clin

ic fo

r fur

ther

man

agem

ent.

Scr

eeni

ng fo

r wom

en w

ith h

igh

risk

is d

one

in a

Spe

cial

ist C

linic

; scr

eeni

ng te

sts

can

be

requ

este

d in

prim

ary

care

but

sho

uld

not d

elay

refe

rral t

o a

Spec

ialis

t Clin

ic .

The

scre

enin

g re

com

men

datio

n fo

r wom

en w

ith h

igh

risk

is M

RI a

djun

ct to

Mam

mog

raph

y.

The

frequ

ency

is d

eter

min

ed b

y th

e le

vel o

f ris

k an

d sh

ould

be

dete

rmin

ed b

y th

e sp

ecia

list.

If po

sitiv

e, re

ferra

l for

trea

tmen

t sho

uld

be m

ade

by th

e sp

ecia

list.

If ne

gativ

e,

scre

enin

g sh

ould

be

cont

inue

d as

det

erm

ined

by

the

spec

ialis

t.

Scre

enin

g in

Men

M

en m

ay d

evel

op b

reas

t can

cer a

nd s

houl

d be

enc

oura

ged

to fe

el th

eir b

reas

t and

che

st

wal

l and

repo

rt to

thei

r doc

tor a

ny lu

mps

or c

hang

e. M

en w

ho h

ave

a B

RC

A1

and

BR

CA

2 ge

ne m

utat

ion,

men

who

hav

e el

evat

ed le

vels

of o

estro

gen

due

to c

erta

in c

ondi

tions

suc

h as

live

r dis

ease

, and

men

on

drug

trea

tmen

t for

pro

stat

e ca

ncer

are

at i

ncre

ased

risk

for

brea

st c

ance

r. O

ther

risk

fact

ors

incl

ude

obes

ity.

Doc

tor m

ay re

com

men

d sc

reen

ing

with

m

amm

ogra

phy

for t

hose

men

who

with

a B

RC

A2

BR

CA

1 m

utat

ion

(23)

.

CH

APT

ER 5

SCR

EEN

ING

GU

IDEL

INE

FO

R B

RE

AST

CAN

CE

R

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Page

5-3

CA

NC

ERS

BR

EAST

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

5.2

Ado

lesc

ence

to

39 y

ears

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on B

reas

t C

ance

r (si

gns

& s

ympt

oms,

ris

k fa

ctor

s, s

cree

ning

)

Yes

Yes

Yes

Hea

lth

prom

otio

n do

ne

at

clin

ics,

sc

hool

s,

club

s,

relig

ious

gro

ups

etc.

with

in th

e co

mm

unity

S

BE

is n

ot in

clud

ed in

the

stan

dard

s fo

r bre

ast c

ance

r scr

eeni

ng.

How

ever

, rou

tine

mon

thly

SB

Es

are

enco

urag

ed; a

ny c

hang

es d

etec

ted

shou

ld tr

igge

r a v

isit

to a

hea

lth c

are

prov

ider

who

will

cond

uct a

CBE

an

d in

vest

igat

e as

nec

essa

ry.

M

onth

ly B

reas

t Sel

f-E

xam

inat

ion

(SB

E)

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Mam

mog

ram

scr

eeni

ng fo

r br

east

can

cer i

s no

t re

com

men

ded.

N/A

N

/A

N/A

C

BE

is to

be

done

if th

ere

is a

po

sitiv

e se

lf-br

east

exa

min

atio

n or

cl

inic

al in

dica

tion.

Thi

s is

ava

ilabl

e at

a

heal

th fa

cilit

y or

in o

utre

ach

setti

ngs

such

as

heal

th fa

irs a

nd

mob

ile u

nits

(e.g

. Jam

aica

Can

cer

Soc

iety

).

C

linic

al b

reas

t exa

min

atio

n (C

BE

) is

to b

e do

ne b

ased

on

clin

ical

ass

essm

ent.

If po

sitiv

e, re

fer t

o a

Yes

Yes

Yes

CH

APT

ER 5

SCR

EEN

ING

GU

IDEL

INE

FO

R B

RE

AST

CAN

CE

R

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Page

5-4

CA

NC

ERS

BR

EAST

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Spe

cial

ist C

linic

for

ev

alua

tion.

Hig

h R

isk:

Req

uest

inve

stig

atio

ns (M

RI

adju

nct t

o m

amm

ogra

phy)

and

re

fer t

o a

Spec

ialis

t Clin

ic

N/A

N

/A

N/A

5.3

Adul

t and

O

lder

Fem

ale

(Age

40-

69

year

s)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on B

reas

t C

ance

r (si

gns

&

sym

ptom

s, ri

sk fa

ctor

s,

scre

enin

g)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics,

w

orkp

lace

s, c

lubs

, rel

igio

us g

roup

s et

c., w

ithin

the

com

mun

ity.

Com

mun

ity s

cree

ning

offe

red

thro

ugh

mob

ile u

nits

S

BE

is n

ot in

clud

ed in

the

stan

dard

s fo

r bre

ast c

ance

r scr

eeni

ng.

How

ever

, rou

tine

mon

thly

SB

Es

are

enco

urag

ed; a

ny c

hang

es d

etec

ted

shou

ld tr

igge

r a v

isit

to a

hea

lth c

are

prov

ider

who

will

cond

uct a

CBE

and

in

vest

igat

e as

nec

essa

ry.

M

onth

ly B

reas

t Sel

f-E

xam

inat

ion

(SB

E)

Yes

Yes

Yes

CH

APT

ER 5

SCR

EEN

ING

GU

IDEL

INE

FO

R B

RE

AST

CAN

CE

R

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Page

5-5

CA

NC

ERS

BR

EAST

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

M

amm

ogra

m s

houl

d be

do

ne o

nce

per y

ear

Yes

Yes

Yes

CB

E is

to b

e do

ne if

ther

e is

a

posi

tive

self-

brea

st e

xam

inat

ion

or

clin

ical

indi

catio

n. T

his

is a

vaila

ble

at

a he

alth

faci

lity

or in

out

reac

h se

tting

s su

ch a

s he

alth

fairs

and

m

obile

uni

ts (e

.g. J

amai

ca C

ance

r S

ocie

ty)

The

net b

enef

its to

scr

een

in h

igh

risk

wom

en a

ged

40 to

49

year

s sh

ould

be

disc

usse

d w

ith th

e pa

tient

. Scr

eeni

ng s

houl

d be

offe

red

in a

Spe

cial

ist C

linic

Th

e ne

t ben

efit

in w

omen

age

d 50

to

69 y

ears

is h

igh.

Scr

eeni

ng s

houl

d be

offe

red

in a

Spe

cial

ist C

linic

. The

st

ruct

ure

or d

esig

n of

this

pro

cess

is

dete

rmin

ed b

y th

e sp

ecia

list.

All

posi

tive

test

s sh

ould

be

refe

rred

to a

Spe

cial

ist C

linic

. H

igh

risk

wom

en s

houl

d be

refe

rred

to a

Spe

cial

ist C

linic

. Scr

eeni

ng te

st

shou

ld b

e in

dica

ted

as a

bas

elin

e.

If

nega

tive,

con

tinue

sc

reen

ing

annu

ally

If

posi

tive,

refe

r to

a S

peci

alis

t Clin

ic f

or

man

agem

ent

Hig

h R

isk:

Req

uest

in

vest

igat

ions

(M

RI

adju

nct t

o m

amm

ogra

phy)

and

re

fer t

o a

Spec

ialis

t Clin

ic.

N/A

N

/A

Yes

CH

APT

ER 5

SCR

EEN

ING

GU

IDEL

INE

FO

R B

RE

AST

CAN

CE

R

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Page

5-6

CA

NC

ERS

BR

EAST

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

5.4

Late

A

dulth

ood

(Old

er F

emal

e ≥7

0 ye

ars)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on B

reas

t C

ance

r (si

gns

&

sym

ptom

s ris

k fa

ctor

s,

scre

enin

g)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics,

w

orkp

lace

s, c

lubs

, rel

igio

us g

roup

s et

c., w

ithin

the

com

mun

ity.

SB

E is

not

incl

uded

in th

e st

anda

rds

for b

reas

t can

cer s

cree

ning

. H

owev

er, r

outin

e m

onth

ly S

BE

s ar

e en

cour

aged

; any

cha

nges

det

ecte

d sh

ould

trig

ger a

vis

it to

a h

ealth

ca

re p

rovi

der w

ho w

ill c

ondu

ct a

C

BE

and

inve

stig

ate

as n

eces

sary

.

B

reas

t Sel

f-Exa

min

atio

n

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

Rou

tine

scre

enin

g no

t re

com

men

ded;

info

rmed

de

cisi

on to

scr

een

or C

BE

N/A

N

/A

N/A

R

egar

ding

mam

mog

raph

y,

evid

ence

in w

omen

age

d ≥7

0 ye

ars

is m

inim

al, a

nd th

e ba

lanc

e of

be

nefit

s an

d ha

rms

cann

ot b

e de

term

ined

. Giv

e ch

oice

to m

ake

an

info

rmed

dec

isio

n to

be

scre

ened

CH

APT

ER 5

SCR

EEN

ING

GU

IDEL

INE

FO

R B

RE

AST

CAN

CE

R

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Page

5-7

Fi

gure

12:

Alg

orith

m fo

r Scr

eeni

ng, R

efer

ral a

nd F

ollo

w U

p in

Wom

en a

t Ave

rage

Ris

k fo

r Bre

ast C

ance

r

Abb

revi

atio

ns: -

ve, n

egat

ive,

+ve

, pos

itive

Wom

en a

t an

aver

age

risk

are

defin

ed a

s su

ch b

ased

on:

No

pers

onal

or f

amily

hi

stor

y of

bre

ast c

ance

r

Pers

onal

or f

amily

his

tory

is

not

ass

ocia

ted

with

BR

CA

1 or

2 g

ene

mut

atio

ns

N

o ch

est r

adia

tion

Res

cree

n

+ve

+ve

+ve

+ve

-ve

-ve

40-6

9 ye

ars

Ref

er to

a S

peci

alis

t C

linic

< 40

yea

rsC

linic

al B

reas

t Ex

amin

atio

n (C

BE)

bas

ed

on c

linic

al a

sses

smen

t

Asy

mpt

omat

ic

wom

en a

t ave

rage

ris

kM

amm

ogra

m o

nce

per

year

70 y

ears

& o

lder

Info

rmed

dec

isio

n to

be

scre

ened

or C

BE

CH

APT

ER 5

SCR

EEN

ING

GU

IDEL

INE

FO

R B

RE

AST

CAN

CE

R

Dat

e Is

sued

: (

) R

evis

ed

(

) N

ew

Page

5-8

Fi

gure

13:

Alg

orith

m fo

r Scr

eeni

ng, R

efer

ral a

nd F

ollo

w u

p in

Wom

en a

t Hig

h R

isk

for B

reas

t Can

cer

*Hig

h ris

k w

omen

sho

uld

be re

ferr

ed to

a S

peci

alis

t Clin

ic. S

cree

ning

test

sho

uld

be in

dica

ted

as a

bas

elin

e.

Asy

mpt

omat

ic

wom

en id

entif

ied

to

be a

t hig

h ris

k

Req

uest

inve

stig

atio

ns (M

RI

adju

nct t

o M

amm

ogra

phy)

and

re

fer t

o a

Spe

cial

ist C

linic

*

Wom

en a

t hig

h ris

k fo

r bre

ast

canc

er a

re d

efin

ed a

s su

ch

base

d on

: 1.

Fa

mily

his

tory

2.

Pr

ior d

iagn

osis

of b

reas

t ca

ncer

3.

C

hest

radi

atio

n 4.

G

enet

ical

ly te

sted

(BR

CA

1 or

2 m

utat

ion

(17)

and

ot

her m

utat

ions

incl

udin

g TP

3 (2

5)

Req

uest

inve

stig

atio

ns (M

RI a

djun

ct to

M

amm

ogra

phy)

and

refe

r to

a Sp

ecia

list

Clin

ic *

Asy

mpt

omat

ic w

omen

id

entifi

ed to

be

at h

igh

risk

S

UB

JEC

T: S

CR

EE

NIN

G G

UID

ELI

NE

S FO

R P

RIO

RIT

Y N

CD

s

P

AG

E 6

-1

Cha

pter

6 S

CR

EE

NIN

G G

UID

ELI

NE

FO

R C

ER

VIC

AL

CA

NC

ER

D

ATE

ISS

UE

D:

(

) R

evis

ed (

) N

ew

6.1

Ris

k G

roup

s an

d Sp

ecia

l Con

side

ratio

ns in

Scr

eeni

ng fo

r Cer

vica

l Can

cer

Indi

cato

r C

onsi

dera

tions

Ris

k As

sess

men

t A

ll w

omen

age

d 21

to 6

5 ye

ars

are

at ri

sk fo

r cer

vica

l can

cer b

ecau

se o

f pot

entia

l exp

osur

e to

hig

h-ris

k H

PV

type

s (h

rHP

V) t

hrou

gh s

exua

l int

erco

urse

and

sho

uld

be s

cree

ned.

It s

houl

d be

cau

tione

d th

at w

omen

at a

vera

ge ri

sk s

houl

d no

t hav

e a

fals

e se

nse

of s

ecur

ity th

at th

ey

will

not

hav

e an

HP

V in

fect

ion

or c

ervi

cal c

ance

r. A

dequ

ate

coun

sellin

g is

requ

ired

by th

e he

alth

car

e pr

ovid

er a

bout

the

poss

ibilit

y of

stil

l hav

ing

an H

PV

infe

ctio

n an

d su

bseq

uent

ly

cerv

ical

can

cer.

Giv

en th

e lo

w u

ptak

e of

cer

vica

l sm

ears

, opp

ortu

nist

ic s

cree

ning

is

reco

mm

ende

d in

all

setti

ngs

incl

usiv

e of

Sex

ually

Tra

nsm

itted

Infe

ctio

n (S

TI) C

linic

s.

Cer

tain

risk

fact

ors

furth

er in

crea

se ri

sk fo

r cer

vica

l can

cer,

incl

udin

g H

IV in

fect

ion,

a

com

prom

ised

imm

une

syst

em, i

n-ut

ero

expo

sure

to d

ieth

ylst

ilboe

stro

l, an

d pr

evio

us

treat

men

t of a

hig

h-gr

ade

prec

ance

rous

lesi

on o

r cer

vica

l can

cer.

Wom

en w

ith th

ese

risk

fact

ors

shou

ld re

ceiv

e in

divi

dual

ized

follo

w-u

p.

Scre

enin

g Te

sts

Scr

eeni

ng w

ith c

ervi

cal c

ytol

ogy

alon

e or

prim

ary

test

ing

for h

rHP

V a

lone

, can

det

ect h

igh-

grad

e pr

ecan

cero

us c

ervi

cal l

esio

ns a

nd c

ervi

cal c

ance

r. C

linic

ians

sho

uld

focu

s on

ens

urin

g th

at w

omen

rece

ive

adeq

uate

scr

eeni

ng, a

ppro

pria

te e

valu

atio

n of

abn

orm

al re

sults

, and

in

dica

ted

treat

men

t, re

gard

less

of w

hich

scr

eeni

ng s

trate

gy is

use

d.

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-2

In

dica

tor

Con

side

ratio

ns

Trea

tmen

t H

igh-

grad

e ce

rvic

al le

sion

s m

ay b

e tre

ated

with

exc

isio

nal a

nd a

blat

ive

ther

apie

s. E

arly

-st

age

cerv

ical

can

cer m

ay b

e tre

ated

with

sur

gery

(hys

tere

ctom

y) o

r che

mot

hera

py.

Wom

en a

t Hig

h R

isk

for C

ervi

cal C

ance

r W

omen

with

HIV

infe

ctio

n, a

com

prom

ised

imm

une

syst

em, i

n ut

ero

expo

sure

to

diet

hyls

tilbo

estro

l, an

d pr

evio

us tr

eatm

ent o

f a h

igh-

grad

e pr

ecan

cero

us le

sion

or c

ervi

cal

canc

er s

houl

d be

scr

eene

d an

nual

ly a

nd re

ceiv

e in

divi

dual

ized

follo

w-u

p. H

IV p

ositi

ve

wom

en s

houl

d id

eally

be

scre

ened

with

HP

V.

Scr

eeni

ng s

houl

d be

com

men

ced

in H

IV p

ositi

ve w

omen

/tran

smen

at t

he a

ge o

f dia

gnos

is

even

if th

ey a

re d

iagn

osed

bel

ow th

e ag

e of

21

year

s.

Spec

ial C

onsi

dera

tions

fo

r Oth

er G

roup

s Tr

ansm

en 2

1 ye

ars

or o

lder

who

hav

e be

en s

exua

lly a

ctiv

e sh

ould

be

scre

ened

for c

ervi

cal

canc

er if

he

reta

ins

a ce

rvix

. For

thos

e w

ho h

ave

unde

rgon

e hy

ster

ecto

my,

scr

eeni

ng w

ill b

e de

pend

ed o

n th

e ty

pe o

f hys

tere

ctom

y. T

rans

men

sho

uld

be s

cree

ned

base

d on

the

inte

rven

tions

alo

ng th

e lif

e co

urse

mod

el a

nd th

eir i

ndiv

idua

l ris

k as

sess

men

t.

(26)

,(27)

,(28)

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-3

CA

NC

ERS

CER

VIC

AL

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

6.2

Chi

ldho

od

&

Ado

lesc

ence

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on H

PV (S

TI)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics

incl

udin

g ST

I Clin

ics,

sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

with

in

the

com

mun

ity

Vac

cina

tion

done

in s

choo

ls, i

n th

e co

mm

unity

via

cam

paig

ns a

nd a

t he

alth

cen

tres

E

duca

tion

on C

ervi

cal C

ance

r (s

igns

& s

ympt

oms,

risk

fact

ors,

pr

even

tion

and

scre

enin

g)

Yes

Yes

Yes

V

acci

natio

n (H

PV

) 2 d

oses

w

ithin

a 6

-mon

th p

erio

d (9

-14

year

s)

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

Scr

eeni

ng n

ot re

com

men

ded

N

/A

N/A

N

/A

6.

3 Ad

ult

Fem

ale

(20-

29

year

s)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on H

PV (S

TI)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics

incl

udin

g ST

I Clin

ics,

sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

with

in

the

com

mun

ity

E

duca

tion

on C

ervi

cal C

ance

r (s

igns

& s

ympt

oms,

risk

fact

ors,

pr

even

tion

and

scre

enin

g)

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Scr

een

for c

ervi

cal c

ance

r eve

ry

3 ye

ars

with

Cyt

olog

y. If

ne

gativ

e, c

ontin

ue s

cree

ning

Yes

Yes

Yes

Rou

tine

HP

V te

stin

g no

t re

com

men

ded

in th

e ag

e gr

oup

21-

29 y

ears

. A

ll ab

norm

al c

ervi

cal c

ells

(low

gr

ade

or h

igh-

grad

e fin

ding

s)

shou

ld b

e re

ferre

d to

a S

peci

alis

t C

linic

.

If

posi

tive,

refe

r to

a Sp

ecia

list

Clin

ic

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-4

CA

NC

ERS

CER

VIC

AL

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

In C

ytol

ogy

if si

gns

of in

fect

ion,

tre

at a

nd re

peat

Cyt

olog

y in

6

mon

ths

If ne

gativ

e, re

scre

en e

very

3 y

ears

H

igh

Ris

k:

S

cree

n w

ith C

ytol

ogy

once

per

ye

ar

Yes

Yes

Yes

Spe

cial

con

side

ratio

ns s

houl

d be

ta

ken

with

the

wom

an w

ho is

HIV

po

sitiv

e, im

mun

o-co

mpr

omis

ed e

tc.

They

sho

uld

be c

onsi

dere

d hi

gh

risk

and

scre

ened

ann

ually

sta

rting

at

the

age

of d

iagn

osis

If

nega

tive,

resc

reen

yea

rly

If

posi

tive,

refe

r to

a Sp

ecia

list

Clin

ic f

or tr

eatm

ent

N/A

Ye

s Ye

s

6.4

Adul

t Fe

mal

e (3

0-49

ye

ars)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on H

PV (S

TI)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics

incl

udin

g ST

I Clin

ics,

sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

with

in

the

com

mun

ity

E

duca

tion

on C

ervi

cal C

ance

r (s

igns

& s

ympt

oms,

risk

fact

ors,

pr

even

tion

and

scre

enin

g)

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

A

ll ab

norm

al c

ervi

cal c

ells

(low

gr

ade

or h

igh-

grad

e fin

ding

s)

shou

ld b

e re

ferre

d to

a S

peci

alis

t C

linic

.

S

cree

n fo

r cer

vica

l can

cer e

very

3

year

s w

ith C

ytol

ogy

alon

e or

w

ith H

PV

test

ing

ever

y 3

year

s al

one

(with

risk

ass

essm

ent)

Yes

Yes

Yes

If

posi

tive,

refe

r to

a Sp

ecia

list

Clin

ic f

or tr

eatm

ent

Yes

Yes

Yes

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-4

CA

NC

ERS

CER

VIC

AL

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

In C

ytol

ogy

if si

gns

of in

fect

ion,

tre

at a

nd re

peat

Cyt

olog

y in

6

mon

ths

If ne

gativ

e, re

scre

en e

very

3 y

ears

H

igh

Ris

k:

S

cree

n w

ith C

ytol

ogy

once

per

ye

ar

Yes

Yes

Yes

Spe

cial

con

side

ratio

ns s

houl

d be

ta

ken

with

the

wom

an w

ho is

HIV

po

sitiv

e, im

mun

o-co

mpr

omis

ed e

tc.

They

sho

uld

be c

onsi

dere

d hi

gh

risk

and

scre

ened

ann

ually

sta

rting

at

the

age

of d

iagn

osis

If

nega

tive,

resc

reen

yea

rly

If

posi

tive,

refe

r to

a Sp

ecia

list

Clin

ic f

or tr

eatm

ent

N/A

Ye

s Ye

s

6.4

Adul

t Fe

mal

e (3

0-49

ye

ars)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on H

PV (S

TI)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics

incl

udin

g ST

I Clin

ics,

sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

with

in

the

com

mun

ity

E

duca

tion

on C

ervi

cal C

ance

r (s

igns

& s

ympt

oms,

risk

fact

ors,

pr

even

tion

and

scre

enin

g)

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

A

ll ab

norm

al c

ervi

cal c

ells

(low

gr

ade

or h

igh-

grad

e fin

ding

s)

shou

ld b

e re

ferre

d to

a S

peci

alis

t C

linic

.

S

cree

n fo

r cer

vica

l can

cer e

very

3

year

s w

ith C

ytol

ogy

alon

e or

w

ith H

PV

test

ing

ever

y 3

year

s al

one

(with

risk

ass

essm

ent)

Yes

Yes

Yes

If

posi

tive,

refe

r to

a Sp

ecia

list

Clin

ic f

or tr

eatm

ent

Yes

Yes

Yes

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-5

CA

NC

ERS

CER

VIC

AL

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Hig

h R

isk:

In

Cyt

olog

y if

sign

s of

infe

ctio

n,

treat

and

repe

at C

ytol

ogy

in 6

m

onth

s.

Spe

cial

con

side

ratio

ns s

houl

d be

ta

ken

with

the

wom

an w

ho is

HIV

po

sitiv

e, im

mun

o-co

mpr

omis

ed,

etc.

If

nega

tive,

resc

reen

eve

ry y

ear

(hig

h ris

k) a

nd e

very

3 y

ears

(a

vera

ge ri

sk)

S

cree

n on

ce p

er y

ear w

ith

Cyt

olog

y or

HP

V te

stin

g Ye

s

Yes

Yes

If

posi

tive,

refe

r a S

peci

alis

t C

linic

for

eva

luat

ion

and

treat

men

t

Yes

Yes

Yes

6.5

Adul

t Fe

mal

e (M

enop

ausa

l &

Imm

edia

te

Post

-M

enop

ausa

l 50

-64

year

s)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on H

PV (S

TI)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics

incl

udin

g ST

I Clin

ics,

sch

ools

, cl

ubs,

relig

ious

gro

ups

etc.

with

in

the

com

mun

ity

E

duca

tion

on C

ervi

cal C

ance

r (s

igns

& s

ympt

oms,

risk

fact

ors,

pr

even

tion

and

scre

enin

g)

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

A

ll ab

norm

al c

ervi

cal c

ells

(low

gr

ade

or h

igh-

grad

e fin

ding

s)

shou

ld b

e re

ferre

d to

a S

peci

alis

t C

linic

. In

Cyt

olog

y if

sign

s of

infe

ctio

n,

treat

and

repe

at C

ytol

ogy

in 6

m

onth

s

S

cree

n fo

r cer

vica

l can

cer e

very

3

year

s w

ith C

ytol

ogy

alon

e or

w

ith H

PV

test

ing

alon

e (w

ith

risk

asse

ssm

ent)

Yes

Yes

Yes

If

posi

tive,

refe

r to

a Sp

ecia

list

Clin

ic fo

r tre

atm

ent

Yes

Yes

Yes

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-6

CA

NC

ERS

CER

VIC

AL

CA

NC

ER

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Hig

h R

isk:

S

peci

al c

onsi

dera

tions

sho

uld

be

take

n w

ith th

e w

oman

who

is H

IV

posi

tive,

imm

uno-

com

prom

ised

, et

c.

If ne

gativ

e re

scre

en e

very

1 y

ear

(hig

h ris

k) a

nd e

very

3 y

ears

(a

vera

ge ri

sk)

S

cree

n on

ce p

er y

ear w

ith

Cyt

olog

y or

HP

V te

stin

g Ye

s Ye

s Ye

s

If

posi

tive,

refe

r to

a Sp

ecia

list

Clin

ic fo

r eva

luat

ion

and

treat

men

t

N/A

N

/A

N/A

6.6

Adul

t Fe

mal

e (6

5 ye

ars

and

olde

r)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on C

ervi

cal C

ance

r (e

mph

asis

on

per v

agin

al

blee

ding

)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics,

cl

ubs,

relig

ious

gro

ups

etc.

, with

in

the

com

mun

ity.

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Rou

tine

scre

enin

g is

not

re

com

men

ded

N/A

N

/A

N/A

A

ll P

V b

leed

sho

uld

be re

ferre

d to

a

Spe

cial

ist C

linic

. W

omen

who

hav

e ha

d 3

cons

ecut

ive

nega

tive

scre

ens

prio

r to

age

65

are

not r

ecom

men

ded

to

be re

scre

ened

. C

onsi

der s

peci

alis

t con

sult

and

scre

enin

g ba

sed

on ri

sk

asse

ssm

ent f

or w

omen

with

less

th

an 3

con

secu

tive

nega

tive

scre

enin

g te

st p

rior t

o ag

e 65

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-7

Fi

gure

14:

Alg

orith

m fo

r Scr

eeni

ng, R

efer

ral a

nd F

ollo

w o

f Wom

en a

t Ave

rage

Ris

k fo

r Cer

vica

l Can

cer

+VE

refe

rral

Wom

en a

t ave

rage

risk

ar

e de

fined

as

such

bas

ed

on:

N

o au

toim

mun

e illn

ess

or c

ompr

omis

ed

imm

une

syst

em

N

o in

ute

ro e

xpos

ure

to d

ieth

ylst

ilboe

stro

l

No

hist

ory

or p

revi

ous

treat

men

t of h

igh-

grad

e pr

ecan

cero

us

lesi

on o

r cer

vica

l ca

ncer

Abb

revi

atio

ns: -

ve, n

egat

ive;

+ve

, pos

itive

*S

peci

alis

t con

sult

and

scre

enin

g if

<3 c

onse

cutiv

e ne

gativ

e sc

reen

ing

test

re

sults

+ve

refe

r

+ve

refe

r+v

e re

fer

+ve

-ve

-ve

21-2

9 Ye

ars

Ref

er to

a S

peci

alis

t C

linic

for T

reat

men

t

Ado

lesc

ent

Scre

enin

g no

t rec

omm

ende

dH

PV V

acci

natio

n: 2

dos

es

betw

een

9-14

yea

rs

(irre

spec

tive

of ri

sk)

Asy

mpt

omat

ic

Fem

ale

at A

vera

ge

Ris

k

Scre

en e

very

3 y

ears

w

ith C

ytol

ogy

ever

y 3

year

s

30-6

4 Ye

ars

Rou

tine

scre

enin

g no

t re

com

men

ded*

65 Y

ears

&

Old

er

Scre

en e

very

3 y

ears

with

C

ytol

ogy

OR

HPV

test

ing

ever

y 3

year

s

Res

cree

n:C

ytol

ogy

ever

y 3

year

s

Res

cree

n:H

PV e

very

3 y

ears

OR

Cyt

olog

y ev

ery

3 ye

ars

+ve

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-8

Fi

gure

15:

Alg

orith

m fo

r Scr

eeni

ng, R

efer

ral a

nd F

ollo

w U

p in

Wom

en a

t Hig

h R

isk

for C

ervi

cal C

ance

r HP

V Te

st

+VE

refe

rral

Abb

revi

atio

ns: -

ve, n

egat

ive,

+ve

, pos

itive

Wom

en a

t hig

her r

isk:

Auto

imm

une

illnes

s or

com

prom

ised

im

mun

e sy

stem

In-u

tero

exp

osur

e to

di

ethy

lstil

boes

trol

H

isto

ry o

r pre

viou

s tre

atm

ent o

f hig

h-gr

ade

prec

ance

rous

le

sion

or c

ervi

cal

canc

er

Ref

erra

l to

a Sp

ecia

list

Clin

ic

Res

cree

n ev

ery

1 ye

ars

with

Cyt

olog

y or

HPV

Te

stin

g

Res

cree

n ev

ery

1 ye

ars

with

Cyt

olog

y or

HPV

Te

stin

g

Res

cree

n ev

ery

year

w

ith C

ytol

ogy

Asy

mpt

omat

ic

wom

en a

t hig

h ris

kSc

reen

with

Cyt

olog

y on

ce p

er y

ear O

R H

PV

test

ing

once

per

yea

r

30-4

9 ye

ars

50-6

4 ye

ars

21-2

9 ye

ars

Scre

en w

ith C

ytol

ogy

or

HPV

Tes

ting

once

per

ye

ar

Scre

en w

ith

Cyt

olog

y on

ce p

er

year

+ve

refe

r

+ve

refe

r

+ve

+ve

-ve

-ve

-ve

Cha

pter

6

SC

REE

NIN

G G

UID

ELIN

E F

OR

CER

VIC

AL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

N

ew

Page

6-9

Fi

gure

16:

Rec

omm

ende

d Pr

imar

y H

PV S

cree

n an

d Tr

eat A

lgor

ithm

Ado

pted

from

(29)

Col

posc

opy

Type

16/

18 P

ositi

ve

Neg

ativ

eR

outin

e Sc

reen

ing

Follo

w u

p in

12

mon

ths

12 o

ther

hrH

PV +

Cyt

olog

yPr

imar

y H

PV

Scre

enin

g

≥ASC-US

NIL

M

S

UB

JEC

T: S

CR

EE

NIN

G G

UID

ELI

NE

S FO

R P

RIO

RIT

Y N

CD

s

P

AG

E 7

-1

Cha

pter

7 S

CR

EE

NIN

G G

UID

ELI

NE

FO

R C

OLO

RE

CTA

L C

AN

CE

R

DA

TE IS

SU

ED

:

(

) Rev

ised

( )

New

7.1

Ris

k G

roup

s an

d Sp

ecia

l Con

side

ratio

ns in

Scr

eeni

ng fo

r Col

orec

tal C

ance

r

Indi

cato

r C

onsi

dera

tions

R

isk

Asse

ssm

ent

Ave

rage

Ris

k G

roup

: Asy

mpt

omat

ic a

dults

45

year

s an

d yo

unge

r who

do

not h

ave

a pe

rson

al o

r fam

ily h

isto

ry o

f kno

wn

gene

tic d

isor

ders

that

pre

disp

ose

them

to a

hig

h lif

etim

e ris

k of

col

orec

tal c

ance

r. N

o pe

rson

al o

f fam

ily h

isto

ry o

f col

orec

tal c

ance

r or

poly

ps.

Hig

h R

isk

Gro

up: F

amilia

l ade

nom

atou

s po

lypo

sis

(FA

P),

infla

mm

ator

y bo

wel

dis

ease

(C

rohn

’s C

oliti

s, U

lcer

ativ

e C

oliti

s), p

erso

nal h

isto

ry o

f pol

yps

and

fam

ily h

isto

ry (f

irst

degr

ee re

lativ

es) o

f pol

yps

and

colo

rect

al c

ance

r, sy

mpt

omat

ic o

r asy

mpt

omat

ic a

dult

with

hi

stor

y of

kno

wn

gene

tic p

redi

spos

ition

to a

hig

h lif

etim

e ris

k of

col

orec

tal c

ance

r (su

ch a

s Ly

nch

synd

rom

e, H

ered

itary

Non

poly

posi

s C

olor

ecta

l Can

cer,

(HN

PC

C).

Old

er a

ge

inci

denc

e in

crea

ses

over

50

year

s. A

ssoc

iate

d ris

k fa

ctor

s ar

e lo

w fi

bre

inta

ke, o

besi

ty,

diab

etes

, sm

okin

g, m

ale

sex,

and

bla

ck ra

ce.

Scre

enin

g Te

sts

The

scre

enin

g te

sts

to d

etec

t ear

ly-s

tage

col

orec

tal c

ance

r, in

clud

es: s

tool

-bas

ed te

sts

–

Gua

iac

Faec

al O

ccul

t Blo

od T

est (

gFO

BT),

Faec

al Im

mun

oche

mic

al T

est (

FIT)

, and

FIT

-D

NA

; dire

ct v

isua

lizat

ion

test

s (fl

exib

le s

igm

oido

scop

y, a

lone

or c

ombi

ned

with

FIT

; co

lono

scop

y); C

T co

lono

grap

hy, a

nd s

erol

ogy

test

s. T

he F

IT te

st h

as th

e hi

ghes

t yie

ld.

The

colo

nosc

opy

has

high

sen

sitiv

ity.

CH

APT

ER 7

:

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

( )

New

Pa

ge 7

-2

A

dapt

ed fr

om (2

9)

Spec

ial

Con

side

ratio

ns

C

lient

s w

ho a

re 7

6 ye

ars

and

olde

r who

hav

e ne

ver b

een

scre

ened

may

be

offe

red

scre

enin

g if

they

are

in g

ood

phys

ical

sta

te, a

nd fr

ee fr

om s

igni

fican

t com

orbi

d co

nditi

ons.

R

isk

bene

fit a

naly

sis

shou

ld b

e do

ne a

nd th

e sc

reen

ing

optio

ns d

iscu

ssed

. The

re s

houl

d be

a lo

w th

resh

old

for c

onsu

ltatio

n an

d re

ferra

l to

a S

peci

alis

t Clin

ic.

FIT-

DN

A is

not

cur

rent

ly re

com

men

ded

for p

opul

atio

n-ba

sed

scre

enin

g. C

T co

lono

grap

hy

is to

be

cons

ider

ed o

nly

in s

elec

t cas

es w

hen

colo

nosc

opy

is c

ontra

indi

cate

d or

not

ac

cept

ed a

nd s

houl

d no

t be

used

as

a su

bstit

ute

for d

irect

vis

ualiz

atio

n te

sts.

Star

ting

and

Stop

ping

Age

s Th

e ev

iden

ce s

ugge

sts

a st

artin

g ag

e of

45y

for t

he J

amai

can

popu

latio

n w

here

>90

% is

of

Afri

can

desc

ent.

The

age

at w

hich

the

bala

nce

of b

enef

its a

nd h

arm

s of

col

orec

tal

canc

er s

cree

ning

bec

omes

less

favo

urab

le v

arie

s ba

sed

on a

pat

ient

's li

fe e

xpec

tanc

y,

heal

th s

tatu

s, c

omor

bid

cond

ition

s, a

nd p

rior s

cree

ning

sta

tus.

Trea

tmen

t and

In

terv

entio

ns

Trea

tmen

t of e

arly

-sta

ge c

olor

ecta

l can

cer g

ener

ally

con

sist

s of

loca

l exc

isio

n or

sim

ple

poly

pect

omy

for t

umou

rs li

mite

d to

the

colo

nic

muc

osa

or s

urgi

cal r

esec

tion

(via

la

paro

scop

y or

ope

n ap

proa

ch) w

ith a

nast

omos

is fo

r lar

ger,

loca

lized

lesi

ons.

CH

APT

ER 7

:

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

7-3

CA

NC

ERS

Col

orec

tal C

ance

r St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

7.2

Adol

esce

nce

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on C

olor

ecta

l C

ance

r (si

gns

& s

ympt

oms,

ris

k fa

ctor

s, s

cree

ning

).

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t sch

ools

, cl

ubs,

relig

ious

gro

ups

etc

., w

ithin

th

e co

mm

unity

. ,

Edu

catio

n on

risk

fact

or

redu

ctio

n, d

iet,

exer

cise

, sm

okin

g, e

tc.

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Rou

tine

scre

enin

g is

not

re

com

men

ded

N/A

N

/A

N/A

Hig

h R

isk:

For a

dole

scen

ts w

ith F

AP

, sc

reen

ing

shou

ld s

tart

at 1

2 ye

ars

of a

ge w

ith

colo

nosc

opy

N/A

N

/A

N/A

A

ll hi

gh-ri

sk p

atie

nts

in th

is a

ge

grou

p in

clud

ing

adol

esce

nts

with

FA

P s

houl

d be

refe

rred

to a

S

peci

alis

t Clin

ic a

nd fo

llow

ed u

p ba

sed

on tr

eatm

ent p

lan

outli

ned

by

the

spec

ialis

t 7.

3 Ad

ulth

ood

(age

20-

44

year

s)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on C

olor

ecta

l C

ance

r (si

gns

& s

ympt

oms,

ris

k fa

ctor

s, s

cree

ning

)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics,

w

orkp

lace

s, c

lubs

, rel

igio

us g

roup

s,

etc.

, with

in th

e co

mm

unity

.

E

duca

tion

on ri

sk fa

ctor

re

duct

ion

diet

, exe

rcis

e,

smok

ing,

etc

.

Yes

Yes

Yes

CH

APT

ER 7

:

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

7-4

CA

NC

ERS

Col

orec

tal C

ance

r St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Rou

tine

scre

enin

g no

t re

com

men

ded

N/A

N

/A

N/A

.

Hig

h R

isk:

Scr

eeni

ng re

com

men

ded

in

patie

nts

with

cer

tain

gen

etic

di

sord

ers

such

as

HN

PCC

w

ith c

olon

osco

py a

nd re

ferra

l to

a S

peci

alis

t Clin

ic

N/A

Ye

s Ye

s A

ll hi

gh-ri

sk p

atie

nts

in th

is a

ge

grou

p sh

ould

be

refe

rred

to a

S

peci

alis

t Clin

ic a

nd fo

llow

ed u

p ba

sed

on tr

eatm

ent p

lan

outli

ned

by th

e sp

ecia

list

7.4

Adul

thoo

d (a

ge 4

5- 7

4 ye

ars)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on C

olor

ecta

l C

ance

r (si

gns

& s

ympt

oms,

ris

k fa

ctor

s, s

cree

ning

)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics,

w

orkp

lace

s, c

lubs

, rel

igio

us g

roup

s,

etc.

, with

in th

e co

mm

unity

.

E

duca

tion

on ri

sk fa

ctor

re

duct

ion

diet

, exe

rcis

e,

smok

ing,

etc

.

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

Scr

een

with

sto

ol-b

ased

test

: gF

OB

T x

3 or

FIT

yea

rly

If

stoo

l tes

t is

posi

tive,

re

fer f

or c

olon

osco

py

(may

be

avai

labl

e at

a

Spe

cial

ist C

linic

)

N/A

Ye

s Ye

s G

uaia

c ba

sed

faec

al o

ccul

t blo

od

test

s (g

FOB

T), i

f use

d, s

houl

d be

do

ne y

early

and

con

sist

of t

hree

st

ool s

ampl

es ta

ken

on d

iffer

ent

days

. Die

t adj

ustm

ents

sho

uld

be

mad

e fo

r sam

ple

colle

ctio

n. T

wo

days

prio

r to

sam

ple

colle

ctio

n,

avoi

d, re

d m

eat,

beet

s, b

rocc

oli,

grap

efru

it, c

anta

lope

, car

rots

,

If

colo

nosc

opy

posi

tive

refe

r to

a Sp

ecia

list

Clin

ic

N/A

Ye

s Ye

s

CH

APT

ER 7

:

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

7-5

CA

NC

ERS

Col

orec

tal C

ance

r St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

If

colo

nosc

opy

is n

egat

ive,

re

scre

en e

very

10

year

s w

ith

colo

nosc

opy

N/A

Ye

s Ye

s cu

cum

ber,

vita

min

-C e

nric

hed

food

s an

d be

vera

ges.

Fa

ecal

imm

unoc

hem

ical

test

ing

(FIT

) can

be

done

yea

rly o

n a

sam

ple

W

here

col

onos

copy

is o

ffere

d at

a

Spe

cial

ist C

linic

then

pos

itive

sto

ol

test

s sh

ould

be

refe

rred

dire

ctly

to

the

Spec

ialis

t Clin

ic

Sto

ol te

st c

ombi

ned

with

Fle

xibl

e S

igm

oido

scop

y ca

n be

use

d fo

r sc

reen

ing,

inst

ead

of c

olon

osco

py,

how

ever

, sho

uld

be d

one

ever

y 5

year

s A

ll pa

tient

s m

ay b

e of

fere

d co

lono

scop

y as

initi

al s

cree

ning

te

st

If th

e co

lono

scop

y is

co

ntra

indi

cate

d or

not

acc

epte

d,

cons

ult a

spe

cial

ist,

cons

ider

CT

colo

nogr

aphy

and

/or d

irect

refe

rral

to a

Spe

cial

ist C

linic

Hig

h R

isk:

Scr

een

with

col

onos

copy

If po

sitiv

e, re

fer t

o a

Spe

cial

ist C

linic

N/A

Ye

s Ye

s

If

nega

tive,

resc

reen

<5

year

s de

pend

ing

on ri

sk

asse

ssm

ent o

r pla

n of

car

e es

tabl

ishe

d by

spe

cial

ist

cons

ult

N/A

Ye

s Ye

s

CH

APT

ER 7

:

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

7-6

CA

NC

ERS

Col

orec

tal C

ance

r St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Follo

w

up

scre

enin

g sh

ould

be

ba

sed

on ri

sk a

sses

smen

t or p

lan

of

care

put

in p

lace

by

the

spec

ialis

t. 7.

5 Ad

ulth

ood

(age

75

year

s or

ol

der)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on C

olor

ecta

l C

ance

r (si

gns

& s

ympt

oms,

ris

k fa

ctor

s, s

cree

ning

)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics,

cl

ubs,

relig

ious

gro

ups

etc

., w

ithin

th

e co

mm

unity

. ,

Edu

catio

n on

risk

fact

or

redu

ctio

n di

et, e

xerc

ise,

sm

okin

g, e

tc.

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

Rou

tine

scre

enin

g no

t re

com

men

ded

N

/A

N/A

N

/A

Scr

eeni

ng is

mos

t app

ropr

iate

for

thos

e he

alth

y en

ough

to u

nder

go

treat

men

t and

thos

e w

ithou

t co

mor

bid

cond

ition

s th

at

sign

ifica

ntly

lim

it th

eir l

ife

expe

ctan

cy

If

a cl

inic

al d

ecis

ion

is m

ade

to s

cree

n, th

e pr

efer

red

mod

ality

sho

uld

be v

ia

Col

onos

copy

N/A

Ye

s Ye

s

CH

APT

ER 7

:

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

7-6

CA

NC

ERS

Col

orec

tal C

ance

r St

age

acro

ss th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

Follo

w

up

scre

enin

g sh

ould

be

ba

sed

on ri

sk a

sses

smen

t or p

lan

of

care

put

in p

lace

by

the

spec

ialis

t. 7.

5 Ad

ulth

ood

(age

75

year

s or

ol

der)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on C

olor

ecta

l C

ance

r (si

gns

& s

ympt

oms,

ris

k fa

ctor

s, s

cree

ning

)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics,

cl

ubs,

relig

ious

gro

ups

etc

., w

ithin

th

e co

mm

unity

. ,

Edu

catio

n on

risk

fact

or

redu

ctio

n di

et, e

xerc

ise,

sm

okin

g, e

tc.

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

Rou

tine

scre

enin

g no

t re

com

men

ded

N

/A

N/A

N

/A

Scr

eeni

ng is

mos

t app

ropr

iate

for

thos

e he

alth

y en

ough

to u

nder

go

treat

men

t and

thos

e w

ithou

t co

mor

bid

cond

ition

s th

at

sign

ifica

ntly

lim

it th

eir l

ife

expe

ctan

cy

If

a cl

inic

al d

ecis

ion

is m

ade

to s

cree

n, th

e pr

efer

red

mod

ality

sho

uld

be v

ia

Col

onos

copy

N/A

Ye

s Ye

s

CH

APT

ER7:

SCR

EEN

ING

GU

IDEL

INE

FOR

CO

LOR

ECTA

LC

ANC

ERD

ate

Issu

ed:

()R

evis

ed

()N

ewPa

ge7-

7

Figu

re17

:Alg

orith

mfo

rthe

Scre

enin

gan

dFo

llow

Up

ofA

dults

atA

vera

geor

Hig

hR

isk

forC

olor

ecta

lCan

cer

Abb

revi

atio

ns:-

ve,n

egat

ive;

+ve,

posi

tive

*Res

cree

nA

vera

geR

isk

Pat

ient

sw

ithne

gativ

eC

olon

osco

pyev

ery

10ye

ars;

resc

reen

Hig

hR

isk

Pat

ient

sw

ithne

gativ

eC

olon

osco

py<

5ye

ars

depe

ndin

gon

risk

asse

ssm

ent

**C

olon

osco

pyin

com

plet

eO

Rno

tava

ilabl

eO

Rpa

tient

unw

illin

gS

ourc

e:m

odifi

ed(3

0)

Ave

rage

risk:

A

ge<4

5ye

ars,

N

ilpe

rson

al/fa

mily

hist

ory

N

ilpr

edis

posi

ngge

netic

fact

ors

Hig

hris

k:

Age

>50

year

s,m

ale,

blac

kra

ce

Ass

ocia

ted

risk

(obe

sity

,sm

okin

g,di

abet

es,l

owfib

erdi

et)

P

erso

nal/f

amily

(clo

se)

colo

rect

alca

ncer

P

redi

spos

ing

gene

ticdi

sord

er(U

lcer

ated

Col

itis,

Cro

hn’s

Col

itis,

fam

iliala

deno

mat

ous

poly

posi

set

c.

Con

tinue

d Sc

reen

ing

until

life

exp

ecta

ncy

< 10

yea

rs*

CO

LON

OSC

OPY

(Can

be

offe

red

as in

itial

sc

reen

ing

optio

n fo

r an

y pa

tient

)

CT

CO

LON

OG

RA

PHY*

*

scre

en w

ith

+ve

-ve

+ve

+ve

-ve

-ve

Susp

icio

us L

esio

n

SPEC

IALI

ST C

LIN

IC

HIG

H-R

ISK

PA

TIEN

T

AVER

AG

E R

ISK

PA

TIEN

T ≥

45

year

s of

age

STO

OL

TES

TIN

G, A

nnua

l FIT

or

Ann

ual g

uaia

c FO

B x

3

S

UB

JEC

T: S

CR

EE

NIN

G G

UID

ELI

NE

S FO

R P

RIO

RIT

Y N

CD

s

P

AG

E 8

-1

Cha

pter

8 S

CR

EE

NIN

G G

UID

ELI

NE

FO

R P

RO

STAT

E C

AN

CE

R

DA

TE IS

SU

ED

:

( )

Rev

ised

(

) N

ew

8.

1 R

isk

Gro

ups

and

Spec

ial C

onsi

dera

tions

in S

cree

ning

for P

rost

ate

Can

cer

Indi

cato

r C

onsi

dera

tions

Ris

k A

sses

smen

t A

vera

ge R

isk:

Asy

mpt

omat

ic m

en le

ss th

an 4

0 ye

ars,

of n

on-A

frica

n de

scen

t, w

ho d

o no

t hav

e a

fam

ily h

isto

ry o

f pro

stat

e ca

ncer

in a

firs

t deg

ree

rela

tive

unde

r 65y

; no

prev

ious

per

sona

l his

tory

of

pro

stat

e ca

ncer

Hig

h R

isk:

Old

er a

ge (>

50y)

, Afri

can

desc

ent,

sym

ptom

atic

men

or a

sym

ptom

atic

men

with

a fa

mily

hi

stor

y of

pro

stat

e ca

ncer

(age

of f

irst d

egre

e re

lativ

e un

der 6

5y),

prev

ious

per

sona

l his

tory

of p

rost

ate

canc

er. M

en w

ith B

RC

A1

or B

RC

A2 m

utat

ion

(any

1 o

r com

bina

tion

of th

ese

fact

ors)

. Ass

ocia

ted

risk

fact

ors

(or f

acto

rs w

hich

acc

eler

ate

pros

tate

can

cer p

rogr

essi

on) i

nclu

de o

besi

ty, h

igh

fat d

iet,

phys

ical

in

activ

ity a

nd s

mok

ing.

Scre

enin

g Te

sts

Scr

eeni

ng fo

r pro

stat

e ca

ncer

beg

ins

with

a d

igita

l rec

tal e

xam

inat

ion

(DR

E).

Sus

pici

ous

DR

E

exam

inat

ions

requ

ire fu

rther

eva

luat

ion

by a

spe

cial

ist.

The

pros

tate

-spe

cific

ant

igen

(PSA

) scr

eeni

ng

test

mea

sure

s th

e am

ount

of P

SA

pro

tein

in th

e bl

ood.

An

elev

ated

PS

A le

vel m

ay b

e ca

used

by

pros

tate

can

cer b

ut c

an a

lso

be c

ause

d by

oth

er c

ondi

tions

, inc

ludi

ng a

n en

larg

ed p

rost

ate

(ben

ign

pros

tatic

hyp

erpl

asia

) and

infla

mm

atio

n of

the

pros

tate

(pro

stat

itis)

. Som

e m

en w

ithou

t pro

stat

e ca

ncer

m

ay th

eref

ore

have

fals

e-po

sitiv

e re

sults

. Men

with

an

elev

ated

PSA

test

resu

lt m

ay u

nder

go a

tra

nsre

ctal

ultr

asou

nd-g

uide

d co

re-n

eedl

e bi

opsy

of t

he p

rost

ate

to d

iagn

ose

pros

tate

can

cer.

CH

APT

ER

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

8-2

8:

Tr

eatm

ent

The

3 m

ost c

omm

on tr

eatm

ent o

ptio

ns fo

r men

with

scr

een-

dete

cted

, loc

aliz

ed p

rost

ate

canc

er a

re

surg

ical

rem

oval

of t

he p

rost

ate

glan

d (ra

dica

l pro

stat

ecto

my)

, rad

iatio

n th

erap

y (e

xter

nal-b

eam

radi

atio

n th

erap

y, p

roto

n be

am th

erap

y, o

r bra

chyt

hera

py),

and

activ

e su

rvei

llanc

e.

Spec

ial

Con

side

ratio

ns

for O

ther

G

roup

s

Pro

stat

e ca

ncer

scr

eeni

ng in

tran

sgen

der w

omen

sho

uld

be b

ased

on

guid

elin

es fo

r non

-tran

sgen

der

men

and

bas

ed o

n th

e lif

e co

urse

app

roac

h. If

a p

rost

ate

exam

is in

dica

ted,

bot

h re

ctal

and

neo

vagi

nal

appr

oach

es m

ay b

e co

nsid

ered

. Tra

nsge

nder

wom

en w

ho h

ave

unde

rgon

e va

gino

plas

ty h

ave

a pr

osta

te

ante

rior t

o th

e va

gina

l wal

l, an

d a

digi

tal n

eova

gina

l exa

m e

xam

inat

ion

may

be

mor

e ef

fect

ive.

(29)

It

shou

ld b

e no

ted

that

whe

n P

SA

test

ing

is p

erfo

rmed

in tr

ansg

ende

r wom

en w

ith lo

w te

stos

tero

ne le

vels

, it

may

be

appr

opria

te to

redu

ce th

e up

per l

imit

of n

orm

al to

1.0

ng/

ml.(

28)

CH

APT

ER

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

8-2

8:

Tr

eatm

ent

The

3 m

ost c

omm

on tr

eatm

ent o

ptio

ns fo

r men

with

scr

een-

dete

cted

, loc

aliz

ed p

rost

ate

canc

er a

re

surg

ical

rem

oval

of t

he p

rost

ate

glan

d (ra

dica

l pro

stat

ecto

my)

, rad

iatio

n th

erap

y (e

xter

nal-b

eam

radi

atio

n th

erap

y, p

roto

n be

am th

erap

y, o

r bra

chyt

hera

py),

and

activ

e su

rvei

llanc

e.

Spec

ial

Con

side

ratio

ns

for O

ther

G

roup

s

Pro

stat

e ca

ncer

scr

eeni

ng in

tran

sgen

der w

omen

sho

uld

be b

ased

on

guid

elin

es fo

r non

-tran

sgen

der

men

and

bas

ed o

n th

e lif

e co

urse

app

roac

h. If

a p

rost

ate

exam

is in

dica

ted,

bot

h re

ctal

and

neo

vagi

nal

appr

oach

es m

ay b

e co

nsid

ered

. Tra

nsge

nder

wom

en w

ho h

ave

unde

rgon

e va

gino

plas

ty h

ave

a pr

osta

te

ante

rior t

o th

e va

gina

l wal

l, an

d a

digi

tal n

eova

gina

l exa

m e

xam

inat

ion

may

be

mor

e ef

fect

ive.

(29)

It

shou

ld b

e no

ted

that

whe

n P

SA

test

ing

is p

erfo

rmed

in tr

ansg

ende

r wom

en w

ith lo

w te

stos

tero

ne le

vels

, it

may

be

appr

opria

te to

redu

ce th

e up

per l

imit

of n

orm

al to

1.0

ng/

ml.(

28)

CH

APT

ER

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

8-3

8:

CA

NC

ERS

Pros

tate

Can

cer

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

8.2

Ado

lesc

ence

H

ealth

Pro

mot

ion

& P

reve

ntio

n

Edu

catio

n on

Pro

stat

e C

ance

r (s

igns

& s

ympt

oms,

risk

fa

ctor

s, s

cree

ning

)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics

(incl

udin

g S

TI C

linic

s), s

choo

ls,

club

s, re

ligio

us g

roup

s et

c. w

ithin

th

e co

mm

unity

E

duca

tion

on ri

sk fa

ctor

re

duct

ion

- di

et, e

xerc

ise,

sm

okin

g et

c.

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

Rou

tine

scre

enin

g is

not

reco

mm

ende

d 8.

3 Ad

ulth

ood

(age

20-

39

year

s)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on P

rost

ate

Can

cer

(sig

ns &

sym

ptom

s, ri

sk

fact

ors,

scr

eeni

ng)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics

(incl

udin

g S

TI C

linic

s), w

orkp

lace

s,

club

s, re

ligio

us g

roup

s et

c., w

ithin

th

e co

mm

unity

.

E

duca

tion

on ri

sk fa

ctor

re

duct

ion

- di

et, e

xerc

ise,

sm

okin

g et

c.

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

Rou

tine

scre

enin

g no

t rec

omm

ende

d

8.4

Adul

thoo

d (a

ge 4

0- 6

9 ye

ars)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on P

rost

ate

Can

cer

(sig

ns &

sym

ptom

s, ri

sk fa

ctor

s,

scre

enin

g)

Yes

Yes

Yes

Hea

lth p

rom

otio

n do

ne a

t clin

ics

(incl

udin

g S

TI C

linic

s), w

orkp

lace

s,

club

s, re

ligio

us g

roup

s et

c., w

ithin

th

e co

mm

unity

.

CH

APT

ER

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

8-4

8:

CA

NC

ERS

Pros

tate

Can

cer

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

E

duca

tion

on ri

sk fa

ctor

re

duct

ion

- die

t, ex

erci

se,

smok

ing

etc

. ,

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

S

cree

n us

ing

DR

E &

PS

A (w

ith

prio

r PS

A C

ouns

ellin

g) e

very

2

year

s

If bo

th n

egat

ive,

repe

at in

2

year

s

Yes

Yes

Yes

Out

reac

h sc

reen

ing

may

be

cond

ucte

d to

iden

tify

men

who

do

not a

ttend

the

sche

dule

d pr

imar

y he

alth

car

e cl

inic

s.

Pat

ient

s re

ferre

d to

a S

peci

alis

t C

linic

sho

uld

be s

imul

tane

ousl

y re

ques

ted

to d

o ad

ditio

nal

inve

stig

atio

ns b

ased

on

clin

ical

as

sess

men

t, su

ch a

s: u

ltras

ound

, ba

sic

bloo

d pa

nel (

bloo

d co

unt,

rena

l fun

ctio

n te

sts

etc.

) whi

ch m

ay

assi

st w

ith th

e sp

ecia

list

cons

ulta

tion,

but

sho

uld

not d

elay

th

e sp

ecia

list r

efer

ral.

All

patie

nts

with

PS

A >

3ng

shou

ld

be re

ferre

d to

a S

peci

alis

t Clin

ic.

If

susp

icio

us D

RE

, ref

er to

a

Spe

cial

ist C

linic

Ye

s Ye

s Ye

s

If

PSA

> 3

ng, r

efer

to a

S

peci

alis

t Clin

ic

Yes

Yes

Yes

If

PSA

<3n

g bu

t >1n

g, re

peat

P

SA

in a

yea

r Ye

s Ye

s Ye

s

If

PSA

<1ng

, scr

een

ever

y 2

year

s Ye

s Ye

s Ye

s

Hig

h R

isk:

Men

age

d 40

- 54

year

s sc

reen

ev

ery

2 ye

ars

Yes

Yes

Yes

Scr

een

with

PSA

and

DR

E

CH

APT

ER

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

8-4

8:

CA

NC

ERS

Pros

tate

Can

cer

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

E

duca

tion

on ri

sk fa

ctor

re

duct

ion

- die

t, ex

erci

se,

smok

ing

etc

. ,

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

A

vera

ge R

isk:

S

cree

n us

ing

DR

E &

PS

A (w

ith

prio

r PS

A C

ouns

ellin

g) e

very

2

year

s

If bo

th n

egat

ive,

repe

at in

2

year

s

Yes

Yes

Yes

Out

reac

h sc

reen

ing

may

be

cond

ucte

d to

iden

tify

men

who

do

not a

ttend

the

sche

dule

d pr

imar

y he

alth

car

e cl

inic

s.

Pat

ient

s re

ferre

d to

a S

peci

alis

t C

linic

sho

uld

be s

imul

tane

ousl

y re

ques

ted

to d

o ad

ditio

nal

inve

stig

atio

ns b

ased

on

clin

ical

as

sess

men

t, su

ch a

s: u

ltras

ound

, ba

sic

bloo

d pa

nel (

bloo

d co

unt,

rena

l fun

ctio

n te

sts

etc.

) whi

ch m

ay

assi

st w

ith th

e sp

ecia

list

cons

ulta

tion,

but

sho

uld

not d

elay

th

e sp

ecia

list r

efer

ral.

All

patie

nts

with

PS

A >

3ng

shou

ld

be re

ferre

d to

a S

peci

alis

t Clin

ic.

If

susp

icio

us D

RE

, ref

er to

a

Spe

cial

ist C

linic

Ye

s Ye

s Ye

s

If

PSA

> 3

ng, r

efer

to a

S

peci

alis

t Clin

ic

Yes

Yes

Yes

If

PSA

<3n

g bu

t >1n

g, re

peat

P

SA

in a

yea

r Ye

s Ye

s Ye

s

If

PSA

<1ng

, scr

een

ever

y 2

year

s Ye

s Ye

s Ye

s

Hig

h R

isk:

Men

age

d 40

- 54

year

s sc

reen

ev

ery

2 ye

ars

Yes

Yes

Yes

Scr

een

with

PSA

and

DR

E

CH

APT

ER

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

8-5

8:

CA

NC

ERS

Pros

tate

Can

cer

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

M

en a

ged

>55

year

s sc

reen

yea

rly

year

ly i

f ag

e gr

eate

r th

an 5

5 an

d ev

ery

2 ye

ars

if ag

e le

ss th

an 5

5

Scr

een

usin

g D

RE

& P

SA

(with

pr

ior P

SA

cou

nsel

ling)

Ye

s Ye

s Ye

s

If

susp

icio

us D

RE

, ref

er to

a

Spe

cial

ist C

linic

Ye

s Ye

s Ye

s

If

PSA

>3n

g, re

fer t

o a

Spe

cial

ist C

linic

Ye

s Ye

s Ye

s

If

PSA

<3n

g bu

t >1n

g, re

peat

P

SA

yea

rly

Yes

Yes

Yes

If

PSA

<1n

g, re

peat

test

bas

ed

on a

ge (1

-2 y

ears

) Ye

s Ye

s Ye

s

8.5

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thoo

d (a

ge 7

0 ye

ars

or o

lder

)

Hea

lth P

rom

otio

n &

Pre

vent

ion

E

duca

tion

on P

rost

ate

Can

cer

(sig

ns &

sym

ptom

s, ri

sk fa

ctor

s,

scre

enin

g)

Yes

Yes

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lth p

rom

otio

n do

ne a

t clin

ics,

w

orkp

lace

s, c

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, rel

igio

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etc.

, with

in th

e co

mm

unity

.

E

duca

tion

on ri

sk fa

ctor

re

duct

ion

- die

t, ex

erci

se,

smok

ing,

etc

.

Yes

Yes

Yes

Scre

enin

g &

Ear

ly D

iagn

osis

R

outin

e sc

reen

ing

is n

ot

reco

mm

ende

d

N/A

N

/A

N/A

S

cree

ning

is m

ost a

ppro

pria

te fo

r th

ose

heal

thy

enou

gh to

und

ergo

tre

atm

ent a

nd th

ose

with

out

CH

APT

ER

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

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ed:

( )

Rev

ised

(

) N

ew

Page

8-6

8:

CA

NC

ERS

Pros

tate

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cer

Stag

e ac

ross

th

e

Life

Cou

rse

Inte

rven

tions

Lo

catio

n w

here

the

inte

rven

tion

shou

ld/c

an b

e ad

dres

sed

Com

mun

ity

1 2

Com

men

ts

If

a cl

inic

al d

ecis

ion

is

mad

e to

scr

een

then

a

PS

A a

nd D

RE

shou

ld b

e do

ne

com

orbi

d co

nditi

ons

that

si

gnifi

cant

ly li

mit

thei

r life

ex

pect

ancy

. A

ll su

spic

ious

DR

E a

nd P

SA

>3ng

sh

ould

be

refe

rred

to a

Spe

cial

ist

Clin

ic

(31)

(32)

(36)

(37)

CH

APT

ER

SCR

EEN

ING

GU

IDEL

INE

FO

R C

OLO

REC

TAL

CAN

CER

D

ate

Issu

ed:

( )

Rev

ised

(

) N

ew

Page

8-7

8:

Fi

gure

18:

Alg

orith

m fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w U

p of

Men

at A

vera

ge a

nd H

igh

Ris

k of

Pro

stat

e C

ance

r A

bbre

viat

ions

: DR

E, D

igita

l Rec

tal E

xam

inat

ion;

PS

A, P

rost

ate

Spe

cific

Ant

igen

*

All

susp

icio

us D

RE

/ P

SA

> 3n

g sh

ould

be

refe

rred

to a

Spe

cial

ist C

linic

; oth

er te

sts

to a

ssis

t with

the

wor

k up

of t

he p

atie

nt m

ay b

e re

ques

ted

but

shou

ld n

ot d

elay

refe

rral

to a

Spe

cial

ist C

linic

C

HA

PTER

SC

REE

NIN

G G

UID

ELIN

E F

OR

CO

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ECTA

L C

ANC

ER

Dat

e Is

sued

: (

) R

evis

ed

( )

New

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ge 8

-7

8:

Fi

gure

18:

Alg

orith

m fo

r Scr

eeni

ng R

efer

ral a

nd F

ollo

w U

p of

Men

at A

vera

ge a

nd H

igh

Ris

k of

Pro

stat

e C

ance

r A

bbre

viat

ions

: DR

E, D

igita

l Rec

tal E

xam

inat

ion;

PS

A, P

rost

ate

Spe

cific

Ant

igen

*

All

susp

icio

us D

RE

/ P

SA

> 3n

g sh

ould

be

refe

rred

to a

Spe

cial

ist C

linic

; oth

er te

sts

to a

ssis

t with

the

wor

k up

of t

he p

atie

nt m

ay b

e re

ques

ted

but

shou

ld n

ot d

elay

refe

rral

to a

Spe

cial

ist C

linic

>40y

Afr

ican

D

esce

nt

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PSA

Scre

en

DR

E Sc

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mpt

omat

ic

men

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Susp

icio

us D

RE*

PSA

resc

reen

in 2

ye

ars

PSA

resc

reen

in

1 y

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SPEC

IALI

ST C

LIN

IC

PSA

<1ng

PSA

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*

PSA

>1ng

<3ng

PSA

<1ng

PSA

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Hig

h R

isk:

1.

Age

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yea

rs2.

A

frica

n de

scen

t3.

P

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nal/

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isto

ry (c

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rost

ate

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er4.

H

isto

ry o

f BR

CA

1/ B

RC

A 2

mut

atio

n

Aver

age

Ris

k

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N

on-A

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n de

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N

il pe

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ory

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er

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18. Siu AL, Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, et al. Screening for depression in children and adolescents: U.S. Preventive services task force recommendation statement. Ann Intern Med. 2016;164(5):360–6.

19. Evidence Summary (Pregnant and Postpartum Women): Depression in Adults: Screening | Document | United States Preventive Services Taskforce [Internet]. [cited 2020 May 28]. Available from: https://www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary-primary-care-screening-for-and-treatment-of/depression-in-adults-screening

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21. Care D, Suppl SS. 14. Management of diabetes in pregnancy: Standards of medical care in diabetesd2019. Diabetes Care. 2019;42(January):S165–72.

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24. De Blok CJM, Wiepjes CM, Nota NM, Van Engelen K, Adank MA, Dreijerink KMA, et al. Breast cancer risk in transgender people receiving hormone treatment: Nationwide cohort study in the Netherlands. BMJ. 2019 May 14;365.

25. WHO position paper on mammography screening [Internet]. 2014 [cited 2020 May 28]. Available from: www.who.

26. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al. Screening for cervical cancer us preventive services task force recommendation statement. JAMA - J Am Med Assoc. 2018 Aug 21;320(7):674–86.

27. WHO. Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. WHO Guidel [Internet]. 2013;60. Available from:

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29. Huh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Garcia FAR, et al. Clinical Commentary Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance ☆. Gynecol Oncol [Internet]. 2014 [cited 2020 May 28]; Available from: http://dx.doi.org/10.1016/j.ygyno.2014.12.022http://dx.doi.org/10.1016/j.ygyno.2014.12.0220090-8258/

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31. Grossman DC, Curry SJ, Owens DK, Bibbins-Domingo K, Caughey AB, Davidson KW, et al. Screening for prostate cancer USPreventive servicestaskforcerecommendation statement. JAMA - J Am Med Assoc. 2018;319(18):1901–13.

32. Recently updated NCCN Clinical Practice Guidelines in OncologyTM [Internet]. [cited 2020 May 28]. Available from: https://www.nccn.org/professionals/physician_gls/recently_updated.aspx

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34. AUA. Early Detection of Prostate Cancer 2018 [updated May 2018. Available from: https://www.auanet.org/guidelines/prostate-cancer-early-detection -guideline. 35. USPSTF. Final Update Summary: Prostate Cancer: Screening. 2018 [cited 2019 Septembe 20r]. Available from: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSumm aryFinal/prostate-cancer-screening1?ds=1&s=prostate. 36. Mottet N, van den Bergh RCN, Briers E, Bourke L, Cornford P, De Santis M, et al. EAU - ESTRO - ESUR - SIOG Guidelines on Prostate Cancer 2018. European Association of Urology Guidelines 2018 Edition. presented at the EAU Annual Congress Copenhagen 2018. Arnhem, The Netherlands: European Association of Urology Guidelines Office; 2018.

37. NCCN. Prostate Cancer: nccn; 2018 [cited 2019 20 September]. Available from: https://www.nccn.org/professionals/physician_gls/pdf/prostate_harmonized- caribbean.pdf. 38. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. 39. World Health Organization. (2012). Prevention and control of noncommunicable

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APPENDICES

APPENDIX A1: Screening of Blood Pressure Values Requiring Further Evaluation in Children & Adolescents

Age BP in mmHg

Female Male SBP DBP SBP DBP

1 98 54 98 52 2 101 58 100 55 3 102 60 101 58 4 103 62 102 60 5 104 64 103 63 6 105 67 105 66 7 106 68 106 68 8 107 69 107 69 9 108 71 107 70

10 109 72 108 72 11 111 74 110 74 12 114 75 113 75

≥13 y 120 80 120 80 Adopted from: American Pediatric Association (38)

Blood pressure readings equal or above the values in the table require repeat readings and further evaluation with BP percentile Chart

APPENDIX A2: Body Mass Index for Age (Z-score)

Girls1

1 World Health Organization (2007). Growth reference 5-19 years. Retrieved from World Health Organization: https://www.who.int/growthref/who2007_bmi_for_age/en/

BMI Status Category Z-Score Range Obesity Above 2 Overweight 2 to above 1 Normal 1 to -2 Thinness Below -2 to -3 Severe Thinness Below -3

Boys2

2 World Health Organization (2007). Growth reference 5-19 years. Retrieved from World Health Organization: https://www.who.int/growthref/who2007_bmi_for_age/en/

APPENDIX A3: World Health Organization Cardiovascular Disease Risk Prediction and Assessment

A - 3.1 CV Risk Prediction Charts - Caribbean

A) Laboratory-based chart: people without diabetes3

3 World Health Organization (2019). WHO updated Cardiovascular Risk Charts. Retrieved from World Health Organization: https://www.who.int/news-room/detail/02-09-2019-who-updates-cardiovascular-risk-charts

B) Laboratory-based chart: people with diabetes4


C) Non-laboratory-based chart5


Comprehensive Clinical Assessment for CV Risk A 3.2

Clinical assessment should be conducted with the aims to: 1. search for all CV risk factors and clinical conditions that may influence prognosis

and treatment 2. determine the presence of target organ damage (heart, kidneys and retina) 3. identify those at high risk and in need of urgent intervention 4. identify those who need special investigations or referral (e.g. those with

secondary hypertension)

Clinical History Full Physical Examination current symptoms of coronary

heart disease, heart failure, cerebrovascular disease, peripheral vascular disease, diabetes and renal disease

information on the use of drugs known to raise blood pressure (oral contraceptives, nonsteroidal anti-inflammatory drugs, cocaine, amfetamine, erythropoietin, cyclosporins and steroids)

family history of high blood pressure, diabetes, dyslipidaemia, coronary heart disease, stroke and renal disease

personal history of coronary heart disease, heart failure, cerebrovascular disease, peripheral vascular disease, diabetes, gout, bronchospasm, sexual dysfunction and renal disease

symptoms suggestive of secondary hypertension, i.e. hypertension caused by an underlying condition

information on behaviour, including tobacco use, physical activity and dietary intake of fat, salt and alcohol

personal, psychosocial, occupational and environmental factors that could influence the course and outcome of long-term care

careful measurement of blood pressure measurement of height and weight, and

calculation of body mass index (BMI) measurement of waist and hip

circumference for calculation of waist–hip ratio

examination of the cardiovascular system, particularly for heart size, evidence of heart failure, evidence of disease in the carotid, renal and peripheral arteries, and physical signs suggestive of coarctation of the aorta, particularly in young people with hypertension

examination for features of secondary hypertension

examination of the lungs for congestion examination of the abdomen for bruits,

enlarged kidneys and other masses examination of the optic fundi and of the

central and peripheral nervous system for evidence of cerebrovascular disease and complications of diabetes

(39)

APPENDIX A4: Summary Full Medical Profile - Major Depression

Clinical Interview At least five of the following symptoms should be present during the same – two-week period.

Depressed mood, as indicated by either subjective report e.g., appears tearful (irritable mood in children and adolescents).

Markedly diminished interest or pleasure in all, or almost all, activities.

Significant weight loss or gain

Insomnia or increased need for sleep

Observable psychomotor agitation or retardation

Fatigue or loss of energy

Feelings of worthlessness or excessive or inappropriate guilt (which may be

delusional)

Diminished ability to think or concentrate, or indecisiveness

Recurrent thoughts of death, recurrent suicidal ideation, plans of suicide Take a detailed history: history of previous episodes of major depression, family history, history of drug use, current medication and previous response to antidepressants. Ask about vegetative symptoms (sleep, appetite, libido). Always evaluate suicidal risk. Conduct physical examination.

Do mental status examination.

Laboratory investigations: There is no lab investigation that is diagnostic of Major Depression. Do complete blood count (CBC), Renal Function Test, HIV and Thyroid Function Tests and consider basic drug screen (cocaine, heroin, marijuana alcohol) or any other test as indicated based on the physical examination and history.

Associated features: Look for associated features such as tearfulness, anxiety symptoms, somatic symptoms e.g. headaches, abdominal pain, lower back pain, etc. The disorder may result in impairment in functioning e.g. sexual problems, interpersonal problems etc. Consider differential diagnosis 1. Other psychiatric disorders e.g. adjustment disorder with depressed mood and

schizoaffective disorder.

2. Substance induced depression e.g. alcohol induced depression.

3. Medication induced depression - may be caused by oral contraceptives, corticosteroids, levodopa, opiates indomethacin benzodiazepines, cimetidine, propranolol, anticholinesterases.

4. Depression due to a medical condition e.g. hypothyroidism, cancer of the head of the pancreas, left anterior stroke, Parkinson’s disease and tuberculosis.

5. Normal bereavement may present with symptoms of major depression. This last for less than six months.

This is a fairly common problem in the adolescent and tends to resemble the adult presentation, but much less so in the pre-adolescent. Depressed adolescents are at risk for a variety of problems later in life including poor social relationships and suicide. In general, behavioral and disrupted attachment symptoms are more common at the younger ages while cognitive and emotional problems are more common at older ages.

Source: Protocol for management of common mental disorders 2013

APPENDIX A5: 6-Item Kutcher Adolescent Depression Scale: KADS-6 NAME: DATE: OVER THE LAST WEEK, HOW HAVE YOU BEEN "ON AVERAGE" OR "USUALLY" REGARDING THE FOLLOWING: 1. Low mood, sadness, feeling blah or down, depressed, just can't be bothered.

a) Hardly Ever b) Much of the time

c) Most of the time

d) All of the time

2. Feelings of worthlessness, hopelessness, letting people down, not being a

good person.


c) Most of the time

d) All of the time

3. Feeling tired, feeling fatigued, low in energy, hard to get motivated, have to

push to get things done, want to rest or lie down a lot


c) Most of the time

d) All of the time

4. Feeling that life is not very much fun, not feeling good when usually

would feel good, not getting as much pleasure from fun things as usual.


c) Most of the time

d) All of the time

5. Feeling worried, nervous, panicky, tense, keyed up, anxious.


c) Most of the time

d) All of the time

6. Thoughts, plans or actions about suicide or self-harm.


c) Most of the time

d) All of the time

TOTAL SCORE: 6 - item KADS scoring: In every item, score:

Hardly Ever = 0

Much of the time = 1

Most of the time = 2

All of the time = 3

then add all 6 item scores to form a single Total Score.

Interpretation of total scores: Total scores at or above 6 Suggest ‘possible depression’ (and a need for more

thorough assessment) Total scores below 6 Indicate ‘probably not depressed’

APPENDIX A6: Patient Health Questionnaire 9-Items (PHQ-9)

Name: Date:

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Questions Not at all Several days More than half the days

Nearly every day

Little interest or pleasure in doing things 0 1 2 3

Feel down, depressed, or hopeless 0 1 2 3

Trouble falling or staying asleep, or sleeping too much

0 1 2 3

Feeling tired or having little energy 0 1 2 3

Poor appetite or overeating 0 1 2 3

Feeling bad about yourself, or that you are a failure or have let yourself or your family down

0 1 2 3

Trouble concentrating on things, such as reading the newspaper or watching television

0 1 2 3

Moving or speaking so slowly that others could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

Thoughts that you would be better off dead, or of hurting yourself

0 1 2 3

TOTAL SCORE = ________ + _________ + __________

To monitor severity over time for newly diagnosed patients or patients in current treatment for depression:

Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment.

Add up score by column. For every: Several days = 1 More than half the days = 2 Nearly every day = 3

Add together column scores to get a TOTAL score.

Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.

Results may be included in patient files to assist you in setting up a treatment goal, determining degree of response, as well as guiding treatment intervention.

Scoring: add up all checked boxes on PHQ-9

For every Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3

Interpretation of Total Score

Total Score Depression Severity

1-4 Minimal depression

5-9 Mild depression

10-14 Moderate depression

15-19 Moderately severe depression

20-27 Severe depression

national screening guidelines for priority non

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