11.3 Disease Prevention

11.3 Disease Prevention

Quick Answer: Disease prevention is structured into primary (prevent occurrence — immunizations, lifestyle), secondary (early detection — screenings), and tertiary (limit complications — chronic disease management) levels. The FPGEE tests ACIP immunization schedules across the lifespan, USPSTF-graded screenings (cardiovascular, cancer, diabetes, infectious, behavioral), vaccine contraindications and administration technique, and non-pharmacological therapies including diet, exercise, sleep, stress, and behavioral interventions. Pharmacists deliver prevention through immunization services, MTM, behavioral counseling, and referral.

Levels of Prevention

• Primary prevention — prevent disease from occurring. Examples: immunizations, smoking cessation, safe sex counseling, motor vehicle safety, lifestyle counseling for healthy weight and exercise.
• Secondary prevention — detect disease early, when treatment is more effective. Examples: cancer screenings (mammography, colonoscopy, Pap), hypertension screening, lipid screening, diabetes screening.
• Tertiary prevention — limit complications of established disease. Examples: cardiac rehab after MI, diabetes complication screening (retinopathy, nephropathy, foot exams), stroke rehab, heart failure disease management.

Immunizations

The Advisory Committee on Immunization Practices (ACIP) publishes the U.S. immunization schedules annually — pediatric (birth–18 years), adult (≥19 years), and catch-up. The CDC Director adopts ACIP recommendations; ACIP recommendations become the standard of care for FPGEE.

Adult Immunization Schedule (key elements)

Pediatric Schedule Principles

The pediatric schedule is dense in the first 2 years: Hepatitis B (birth, 1–2 months, 6–18 months), RV (rotavirus, live oral, 2 and 4 months), DTaP (2, 4, 6, 15–18 months, 4–6 years), Hib (2, 4, 6 [depending on brand], 12–15 months), PCV (pneumococcal conjugate, series through 5 years), IPV (inactivated polio, 4 doses), influenza (annual ≥6 months), MMR (12–15 months, 4–6 years), varicella (same as MMR), Hepatitis A (12–23 months, 2 doses), HPV (start 11–12 years), Tdap (11–12 years), MenACWY (11–12, booster 16), MenB (16–18 shared decision).

Vaccine Contraindications and Precautions

A contraindication means the vaccine should not be given; a precaution means weigh the risk-benefit. Severe allergic reaction (anaphylaxis) to a previous dose or component is a contraindication to all vaccines. Egg allergy is no longer a contraindication to influenza (IIV) or MMR — the CDC and ACIP have removed this precaution; patients with egg allergy of any severity can receive any flu vaccine appropriate to age. Yellow fever vaccine still warrants egg allergy precaution. Pregnancy is a contraindication to live vaccines (MMR, varicella, LAIV, rotavirus). Severe immunocompromise is a contraindication to live vaccines (live vaccines can replicate). Moderate or severe acute illness is a precaution for any vaccine (defer until recovered; mild illness is fine). Guillain-Barré syndrome within 6 weeks of a previous flu vaccine is a precaution for subsequent influenza vaccines. Pregnancy is also a precaution for HPV and zoster live (Zostavax) — though Zostavax is no longer used in the US. RSV vaccination in pregnancy is targeted to 32–36 weeks during September–January.

Vaccine Administration

Multiple vaccines can be given at the same visit in separate anatomical sites (≥1 inch apart). Document each in the patient's record and the state immunization registry.

Pharmacists' Role in Immunization

All 50 states authorize pharmacists to immunize (scope varies by state and vaccine, with age limits). Pharmacists are essential to adult immunization access — particularly influenza, COVID-19, pneumococcal, shingles, and travel vaccines. The Public Readiness and Emergency Preparedness (PREP) Act amendments during COVID-19 expanded pharmacist authority for pediatric and routine vaccines; state law ultimately governs the durable scope.

Screenings (USPSTF)

The U.S. Preventive Services Task Force (USPSTF) grades recommendations:

• Grade A — substantial net benefit; provide the service.
• Grade B — moderate net benefit; provide the service.
• Grade C — small net benefit; offer selectively based on professional judgment and patient values.
• Grade D — harm outweighs benefit; discourage.
• Grade I — insufficient evidence to assess balance.

The Affordable Care Act (ACA) requires non-grandfathered private insurance and Medicaid expansion plans to cover A and B services without patient cost-sharing.

Cardiovascular Screenings

• Blood pressure: screen all adults ≥18 (Grade A ≥18 with hypertension risk; the USPSTF 2021 update reaffirmed screening). Treat to standard targets.
• Lipids: screen adults ≥20 at risk, men ≥35, women ≥45 (Grade B); statin for adults 40–75 with ≥10% 10-year ASCVD risk and an LDL ≥70 mg/dL (Grade B).
• ASCVD risk calculator: estimates 10-year risk using age, sex, race, total cholesterol, HDL, BP, treatment, diabetes, smoking.
• Coronary artery calcium (CAC) score: useful for intermediate-risk patients to refine statin decision (CAC=0 favors withholding; CAC ≥100 or ≥75th percentile favors statin).
• Aspirin for primary prevention: USPSTF 2022 — initiate low-dose aspirin for adults 40–59 with ≥10% 10-year ASCVD risk who are willing to take it (Grade C); do not initiate for ≥60 (Grade D); individualize continuation.
• Abdominal aortic aneurysm (AAA): one-time ultrasound for men 65–75 who have ever smoked (Grade B).

Cancer Screenings

• Colorectal: adults 45–75 (Grade A); 76–85 individualized (Grade C). Options include colonoscopy q10y, FIT yearly, Cologuard (sDNA-FIT) q3y, CT colonography q5y. Screening >85 is Grade D.
• Breast (mammography): biennial 40–74 (Grade B, 2024 update lowered start age to 40). Individualize for ≥75 (Grade I).
• Cervical (Pap/HPV): 21–29 cytology q3y; 30–65 cytology q3y, HPV q5y, or co-testing q5y. Discontinue after 65 with adequate prior screening and not high-risk; post-hysterectomy for benign reasons.
• Lung (low-dose CT): adults 50–80, ≥20 pack-year history, currently smoke or quit <15 years (Grade B).
• Prostate (PSA): men 55–69 — individualized shared decision (Grade C); 70+ — do not screen routinely (Grade D).
• Skin: insufficient evidence for routine screening (Grade I); consider for high-risk patients.

Diabetes Screening

USPSTF (2021): screen adults 35–70 with overweight or obesity (Grade B); earlier screening for adults at higher risk (family history, high-risk race/ethnicity, history of gestational diabetes, PCOS, CVD). Methods: fasting plasma glucose (FPG ≥126 mg/dL), oral glucose tolerance test (OGTT 2-hour ≥200 mg/dL), or HbA1c ≥6.5%. Confirm with repeat testing.

Other Screenings

• Osteoporosis (DEXA): women ≥65 (Grade B); younger postmenopausal women at increased risk; men — individualized (USPSTF Grade I for routine men).
• Depression (PHQ-9): adults (Grade B); adolescents 12–18 (Grade B).
• HIV: screen 15–65, younger/older at risk, all pregnancies (Grade A).
• Hepatitis C: adults 18–79 (Grade B); CDC recommends one-time screening for all adults ≥18.
• Hepatitis B: screen adults at risk, all pregnancies (Grade A/B).
• STIs (chlamydia/gonorrhea/syphilis): per age and risk groups.
• Vision/hearing: older adults (Grade B/C/I depending).

Non-Pharmacological Therapies and Lifestyle Modifications

Diet and Nutrition

• DASH diet (Dietary Approaches to Stop Hypertension): high in fruits, vegetables, low-fat dairy; reduces systolic BP by ~8–14 mmHg; first-line lifestyle intervention for hypertension.
• Mediterranean diet: olive oil, nuts, fish, whole grains, modest wine; reduces CV events (PREDIMED trial).
• Low-sodium diet (<2,300 mg/day, ideally <1,500 mg/day for hypertension).
• Heart-healthy eating patterns reduce LDL and CV risk.

Exercise

ACSM/AHA guidelines: at least 150 minutes/week of moderate-intensity aerobic activity (or 75 min/week vigorous, or equivalent combination), plus muscle-strengthening activities on ≥2 days/week. Older adults should add balance training. For weight loss, 200–300 minutes/week of moderate activity is recommended.

Weight Management

Calculate BMI (kg/m²); ≥25 overweight (≥23 in Asian populations), ≥30 obesity. Waist circumference ≥40" men, ≥35" women indicates abdominal obesity. Combine diet, exercise, behavioral therapy; pharmacotherapy (orlistat, phentermine/topiramate, naltrexone/bupropion, GLP-1 agonists) and bariatric surgery for select patients.

Smoking Cessation

Apply the 5 A's: Ask about tobacco use, Advise to quit, Assess willingness, Assist with counseling + pharmacotherapy (NRT, varenicline, bupropion), Arrange follow-up. See 11.2 for pharmacotherapy details.

Alcohol and Substance Use

Screen with AUDIT-C or AUDIT; brief intervention for risky drinking; refer for treatment when use disorder is identified. Alcohol moderation: ≤2 drinks/day men, ≤1 drink/day women (Dietary Guidelines).

Sleep and Stress

• Sleep hygiene: consistent schedule, dark/cool room, no screens before bed, avoid caffeine late, limit naps, exercise (not within 3 hours of bed), avoid alcohol before bed.
• Stress management: mindfulness, meditation, breathing exercises, yoga, exercise, social support, CBT for insomnia (CBT-I) and stress.

Behavioral Interventions

Cognitive Behavioral Therapy (CBT) is first-line for depression, anxiety, insomnia, and chronic pain; motivational enhancement therapy for substance use; behavioral weight loss programs for obesity. Pharmacists can refer and reinforce.

Physical and Occupational Therapy

Refer for PT after musculoskeletal injury, stroke, surgery, or with mobility limitations. Refer for OT for activities of daily living adaptations, fall prevention, and cognitive rehabilitation. Cardiac and pulmonary rehabilitation are tertiary prevention after CV/pulmonary events.

Pharmacist-Led Prevention Services

• Immunization delivery (influenza, COVID-19, pneumococcal, shingles, travel).
• MTM — comprehensive medication review identifies untreated indications, duplicate therapy, and need for preventive medications (statins, antihypertensives).
• Self-measured BP monitoring programs with pharmacist titration under collaborative practice agreements.
• Smoking cessation programs (counseling + NRT/varenicline/bupropion).
• Diabetes prevention programs (DPP) — lifestyle coaching for prediabetes.
• Screening and referral (BP, glucose, HIV self-test distribution, naloxone).
• Point-of-care testing (A1c, lipids, INR, HIV, COVID-19).