This is the current release of the guideline.

This guideline updates a previous version: Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Sections 107-132: surgery. In: Children's Oncology Group. Bethesda (MD): Children's Oncology Group; 2006 Mar. p. 26. [110 references]

Late effects resulting from surgery to treat pediatric malignancies

Effects include complications from amputation, cystectomy, enucleation, hysterectomy, laparotomy, limb sparing procedure, nephrectomy, brain or spinal cord surgery, female or male reproductive surgery, splenectomy, thyroidectomy, pelvic or pulmonary surgery and use of a central venous catheter.

Note: "Late effects" are defined as therapy-related complications or adverse effects that persist or arise after completion of treatment for a pediatric malignancy. "Pediatric malignancies" are defined as those malignancies commonly associated with the pediatric population that may arise during childhood, adolescence or young adulthood.

Asymptomatic survivors of childhood, adolescent, or young adult cancers who were treated surgically and who present for routine exposure-related medical follow-up

Thorough history and physical examination, and targeted screening evaluations

Therapy-related complications or adverse effects that persist or arise after completion of treatment for a pediatric malignancy

Pertinent information from the published medical literature over the past 20 years (updated as of October 2008) was retrieved and reviewed during the development and updating of these guidelines. For each therapeutic exposure, a complete search was performed via MEDLINE (National Library of Medicine, Bethesda, MD). Keywords included "childhood cancer therapy," "complications," and "late effects," combined with keywords for each therapeutic exposure. References from the bibliographies of selected articles were used to broaden the search.

Not stated

The guidelines were scored by the multidisciplinary panel of experts using a modified version of the National Criteria: Comprehensive Cancer Network "Categories of Consensus" system. Each score reflects the expert panel's assessment of the strength of data from the literature linking a specific late effect with a therapeutic exposure, coupled with an assessment of the appropriateness of the screening recommendation based on the expert panel's collective clinical experience. "High-level evidence" (category 1) was defined as evidence derived from high quality case control or cohort studies. "Lower-level evidence" (categories 2A and 2B) was defined as evidence derived from non-analytic studies, case reports, case series and clinical experience. Rather than submitting recommendations representing major disagreements, items scored as "Category 3" were either deleted or revised by the panel of experts to provide at least a "Category 2B" score for all recommendations included in the guidelines.

In 2002, the leadership of the Children's Oncology Group (COG) Late Effects Committee and Nursing Discipline appointed a 7-member task force, with representation from the Late Effects Committee, Nursing Discipline, and Patient Advocacy Committee. The task force was convened to review and summarize the medical literature and develop a draft of clinical practice guidelines to direct long-term follow-up care for pediatric cancer survivors. The task force followed a modified version of the guideline development process established by the National Comprehensive Cancer Network (NCCN), integrating available literature with expert opinion using reiterative feedback loops.

The original draft went through several iterations within the task force prior to initial review. Multidisciplinary experts in the field, including nurses, physicians (pediatric oncologists and other subspecialists), patient advocates, behavioral specialists, and other healthcare professionals, were then recruited by the task force to provide an extensive, targeted review of the draft, including focused review of selected guideline sections. Revisions were made based on these recommendations. The revised draft was then sent out to additional multidisciplinary experts for further review. A total of 62 individuals participated in the review process. The guidelines subsequently underwent comprehensive review and scoring by a panel of experts in the late effects of pediatric malignancies, comprised of multidisciplinary representatives from the COG Late Effects Committee.

Revisions

In order to keep the guidelines current and clinically meaningful, the COG Late Effects Committee organized 18 multi-disciplinary task forces in March 2004. These task forces were charged with the responsibility for monitoring the medical literature in regard to specific system-related clinical topics relevant to the guidelines (e.g., cardiovascular, neurocognitive, fertility/reproductive), providing periodic reports to the Late Effects Committee, and recommending revisions to the guidelines and their associated health education materials and references (including the addition of therapeutic exposures) as new information became available. Task force members were assigned according to their respective areas of expertise and clinical interest. A list of these task forces and their membership is included in the "Contributors" section of the original guideline document. The revisions incorporated into the previous (Version 2.0 – March 2006) and current (Version 3.0 – October 2008) release of these guidelines reflect the contributions and recommendations of these task forces.

All revisions proposed by the task forces were evaluated by a panel of experts, and if accepted, assigned a score (see "Rating Scheme for the Strength of the Evidence"). Proposed revisions that were rejected by the expert panel were returned with explanation to the relevant task force chair. If desired, task force chairs were given an opportunity to respond by providing additional justification and resubmitting the rejected task force recommendation(s) for further consideration by the expert panel. A total of 34 sections and 9 Health Links were added to Version 2.0 of these guidelines.

Each score relates to the strength of the association of the identified late effect with the specific therapeutic exposure based on current literature, and is coupled with a recommendation for periodic health screening based on the collective clinical experience of the panel of experts. This is due to the fact that there are no randomized clinical trials (and none forthcoming in the foreseeable future) on which to base recommendations for periodic screening evaluations in this population; therefore, the guidelines should not be misconstrued as representing conventional "evidence-based clinical practice guidelines" or "standards of care."

Each item was scored based on the level of evidence currently available to support it. Scores were assigned according to a modified version of the National Comprehensive Cancer Network "Categories of Consensus," as follows:

Uniform consensus: Near-unanimous agreement of the panel with some possible neutral positions.
Non-uniform consensus: The majority of panel members agree with the recommendation; however, there is recognition among panel members that, given the quality of evidence, clinicians may choose to adopt different approaches.
High-level evidence: Evidence derived from high quality case control or cohort studies.
Lower-level evidence: Evidence derived from non-analytic studies, case reports, case series, and clinical experience.

A formal cost analysis was not performed and published cost analyses were not reviewed.

The initial version of the guidelines (Version 1.0 – Children's Oncology Group Late Effects Screening Guidelines) was released to the Children's Oncology Group (COG) membership in March 2003 for a six-month trial period. This allowed for initial feedback from the COG membership, resulting in additional review and revision of the guidelines by the Late Effects Committee prior to public release.

Revisions

All revisions proposed by the task forces were evaluated by a panel of experts, and if accepted, assigned a score (see "Rating Scheme for the Strength of the Evidence"). Proposed revisions that were rejected by the expert panel were returned with explanation to the relevant task force chair. If desired, task force chairs were given an opportunity to respond by providing additional justification and resubmitting the rejected task force recommendation(s) for further consideration by the expert panel.

Grades of recommendations (1, 2A, 2B, 3) are defined at the end of the "Major Recommendations" field.

Note from the Children's Oncology Group and the National Guideline Clearinghouse (NGC): The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers (COG LTFU) are organized according to therapeutic exposures; this guideline has been divided into individual summaries. In addition to the current summary, the following are available:

• Sections 1–2: any cancer experience
• Sections 3–5: blood/serum products
• Sections 6–37: chemotherapy
• Sections 38–91: radiation
• Sections 92–106: hematopoietic cell transplant
• Sections 133–136: other therapeutic modalities
• Sections 137–146: cancer and general health screening

In order to accurately derive individualized screening recommendations for a specific childhood cancer survivor using this guideline, see "Using the COG LTFU Guidelines to Develop Individualized Screening Recommendations" in the original guideline document . (Note: For ease of use, a Patient-Specific Guideline Identification Tool has been developed to streamline the process and is included in Appendix I  of the original guideline document.)

Guideline Organization

The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers are organized according to therapeutic exposures, arranged by column as follows:

System	Body system (e.g., auditory, musculoskeletal) most relevant to each guideline section.
Score	Score assigned by expert panel representing the strength of data from the literature linking a specific late effect with a therapeutic exposure coupled with an assessment of the appropriateness of the screening recommendation based on collective clinical experience.
Section Number	Unique identifier for each guideline section.
Therapeutic Agent	Therapeutic intervention for malignancy, including chemotherapy, radiation, surgery, blood/serum products, hematopoietic cell transplant, and other therapeutic modalities.
Potential Late Effects	Most common late treatment complications associated with specified therapeutic intervention.
Risk Factors	Host factors (e.g., age, sex, race, genetic predisposition), treatment factors (e.g., cumulative dose of therapeutic agent, mode of administration, combinations of agents), medical conditions (e.g., pre-morbid or co-morbid conditions), and health behaviors (e.g., diet, smoking, alcohol use) that may increase risk of developing the complication.
Highest Risk Factors	Conditions (host factors, treatment factors, medical conditions and/or health behaviors) associated with the highest risk for developing the complication.
Periodic Evaluations	Recommended screening evaluations, including health history, physical examination, laboratory evaluation, imaging, and psychosocial assessment. Recommendation for minimum frequency of periodic evaluations is based on risk factors and magnitude of risk, as supported by the medical literature and/or the combined clinical experience of the reviewers and panel of experts.
Health Counseling/ Further Considerations	Health Links: Health education materials developed specifically to accompany these guidelines. Title(s) of Health Link(s) relevant to each guideline section are referenced in this column. Health Link documents are included in Appendix II  of the original guideline document. Counseling: Suggested patient counseling regarding measures to prevent/reduce risk or promote early detection of the potential treatment complication. Resources: See the original guideline document for lists of books and websites that may provide the clinician with additional relevant information. Considerations for Further Testing and Intervention: Recommendations for further diagnostic evaluations beyond minimum screening for individuals with positive screening tests, recommendations for consultation and/or referral, and recommendations for management of exacerbating or predisposing conditions.
References	References are listed immediately following each guideline section in the original guideline document. Included are medical citations that provide evidence for the association of the therapeutic intervention with the specific treatment complication and/or evaluation of predisposing risk factors. In addition, some general review articles have been included in the Reference section of the original guideline document for clinician convenience.

Note: See the end of the "Major Recommendations" field for explanations of abbreviations included in the summary.

Amputation

System = Musculoskeletal
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Central Venous Catheter

System = Cardiovascular
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Cystectomy

System = Urinary
Score =

Chronic urinary tract infection: 1
Renal dysfunction: 1
Vesicoureteral reflux: 1
Hydronephrosis: 1
Spontaneous neobladder perforation: 1
Reservoir calculi: 2A
Vitamin B12/folate/carotene deficiency: 2B

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Enucleation

System = Ocular
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Hysterectomy

System = Reproductive (Female)
Score = 2A

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Laparotomy

System = GI/Hepatic
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Limb Sparing Procedure

System = Musculoskeletal
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Nephrectomy

System = Urinary
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Neurosurgery – Brain

System = CNS
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = CNS
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = CNS
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = CNS
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Neurosurgery – Spinal Cord

System = CNS
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = CNS
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = CNS
Score = 2A

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Oophoropexy

System = Reproductive (Female)
Score = 2A

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Oophorectomy (Unilateral)

System = Reproductive (Female)
Score = 2A

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Oophorectomy (Bilateral)

System = Reproductive (Female)
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Orchiectomy

Reproductive (Male)

System = Male Reproductive
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Pelvic Surgery

System = Urinary
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = GI/Hepatic
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Reproductive (Male/Female)
Score = 2A

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Urinary
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Pulmonary

System = Pulmonary
Score = 2A

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Splenectomy

System = Immune
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Thyroidectomy

System = Endocrine/Metabolic
Score = 1

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Abbreviations

• BUN, blood urea nitrogen
• Ca, calcium
• CBC, complete blood count
• Cl, chloride
• CNS, central nervous system
• CO₂, carbon dioxide
• CXR, chest x-ray
• DLCO, diffusion capacity of carbon monoxide
• DOE, dyspnea on exertion
• FSH, follicle stimulating hormone
• GI, gastrointestinal
• GVHD, graft versus host disease
• Gy, gray
• HIB, Haemophilus influenza b vaccine
• HRT, hormone replacement therapy
• IO, intraosseous
• IQ, intelligence quotient
• IT, intrathecal
• IV, intravenous
• K, potassium
• KUB, kidneys, ureter, bladder radiograph
• LH, luteinizing hormone
• Mg, magnesium
• Na, sodium
• NCI, National Cancer Institute
• NSAIDs, non-steroidal anti-inflammatory drugs
• PCN, penicillin
• PFTs, pulmonary function tests
• PO₄, phosphate
• PPV23, pneumococcal polysaccharides vaccine, 23-valent
• SOB, shortness of breath
• T, temperature
• T4, thyroxine
• TBI, total body irradiation
• TSH, thyroid stimulating hormone
• UK, United Kingdom
• V-A, ventriculoatrial
• V-P, ventriculoperitoneal
• V-V, ventriculovenous

Definitions:

Explanation of Scoring for the Long-Term Follow-Up Guidelines

Each item was scored based on the level of evidence currently available to support it. Scores were assigned according to a modified version of the National Comprehensive Cancer Network "Categories of Consensus," as follows:

Uniform consensus: Near-unanimous agreement of the panel with some possible neutral positions.
Non-uniform consensus: The majority of panel members agree with the recommendation; however, there is recognition among panel members that, given the quality of evidence, clinicians may choose to adopt different approaches.
High-level evidence: Evidence derived from high quality case control or cohort studies.
Lower-level evidence: Evidence derived from non-analytic studies, case reports, case series, and clinical experience.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Although several well-conducted studies on large populations of childhood cancer survivors have demonstrated associations between specific exposures and late effects, the size of the survivor population and the rate of occurrence of late effects does not allow for clinical studies that would assess the impact of screening recommendations on the morbidity and mortality associated with the late effect. Therefore, scoring of each exposure reflects the expert panel's assessment of the level of literature support linking the therapeutic exposure with the late effect coupled with an assessment of the appropriateness of the recommended screening modality in identifying the potential late effect based on the panel's collective clinical experience.

Potential benefits of implementing these guidelines into clinical practice include earlier identification of and intervention for late onset therapy-related complications in this at-risk population, potentially reducing or ameliorating the impact of late complications on the health status of survivors. In addition, ongoing healthcare that promotes healthy lifestyle choices and provides ongoing monitoring of health status is important for all cancer survivors.

Potential harms of guideline implementation include increased patient anxiety related to enhanced awareness of possible complications, as well as the potential for false-positive screening evaluations, leading to unnecessary further workup. In addition, costs of long-term follow-up care may be prohibitive for some patients, particularly those lacking health insurance, or those with insurance that does not cover the recommended screening evaluations.

Implementation of these guidelines is intended to standardize and enhance follow-up care provided to survivors of pediatric malignancies throughout the lifespan. Considerations in this regard include the practicality and efficiency of applying these broad guidelines in individual clinical situations. Studies to address guideline implementation and refinement are a top priority of the Children's Oncology Group (COG) Long-Term Follow-Up Guideline Core Committee, and proposals to study feasibility of guideline use in limited institutions are currently underway. Issues to be addressed include description of anticipated barriers to application of the recommendations in the guidelines and development of review criteria for measuring changes in care when the guidelines are implemented. Additional concerns surround the lack of current evidence establishing the efficacy of screening for late complications in pediatric cancer survivors. While most clinicians believe that ongoing surveillance for these late complications is important in order to allow for early detection and intervention for complications that may arise, development of studies addressing the efficacy of this approach is imperative in order to determine which screening modalities are optimal for asymptomatic survivors.

In addition, the clinical utility of this lengthy document has also been a top concern of the COG Long-Term Follow-Up Guideline Core Committee. While recognizing that the length and depth of these guidelines is important in order to provide clinically-relevant, evidence-based recommendations and supporting health education materials, clinician time limitations and the effort required to identify the specific recommendations relevant to individual patients have been identified as barriers to their clinical application. Therefore, the COG Long-Term Follow-Up Guideline Core Committee is currently partnering with the Baylor School of Medicine in order to develop a web-based interface, known as "Passport for Care," that will generate individualized exposure-based recommendations from these guidelines in a clinician-focused format for ease of patient-specific application of the guidelines in the clinical setting. As additional information regarding implementation of the Passport for Care web-based interface becomes available, updates will be posted at www.survivorshipguidelines.org .

Not applicable: The guideline was not adapted from another source.

This work was supported by the Children's Oncology Group grant U10 CA098543 from the National Cancer Institute.

Children's Oncology Group's Long-Term Follow-Up Guidelines Core Committee

Committee Members: Melissa M. Hudson, MD, Co-Chair – COG LTFU Guidelines Core Committee, Member, Department of Hematology-Oncology Director, Cancer Survivorship Division, Co-Leader, Cancer Prevention & Control Program, St. Jude Children's Research Hospital, Memphis, TN; Wendy Landier, RN, MSN, CPNP, CPON®; Co-Chair – COG LTFU Guidelines Core Committee, Clinical Director, Center for Cancer Survivorship City of Hope National Medical Center, Duarte, CA; Louis S. Constine, MD, F.A.S.T.R.O., Co-Chair – COG LTFU Guidelines Core Committee, Professor of Radiation Oncology and Pediatrics, Vice Chair, Department of Radiation Oncology, James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY; Smita Bhatia, MD, MPH, Co-Chair – COG LTFU Guidelines Core Committee, Professor and Chair, Department of Population Sciences, City of Hope National Medical Center, Associate Director, Population Research, City of Hope Comprehensive Cancer Center, Duarte, CA; F. Daniel Armstrong, PhD, Professor and Associate Chair, Department of Pediatrics Director, Mailman Center for Child Development, University of Miami School of Medicine, Miami, FL; Joan Darling, PhD, COG Patient Advocacy Committee Representative, Lincoln, NE; Paul Graham Fisher, MD, MHS, Associate Professor, Neurology and Pediatrics, The Beirne Family Director of Neuro-Oncology at Packard Hospital, Stanford University Medical Center, Stanford, CA; Debra L. Friedman MD, MS, Associate Professor of Pediatrics, Ingram Distinguished Chair in Pediatric Oncology, Leader, Cancer Control and Prevention Program, Vanderbilt Ingram Cancer Center Nashville, TN, Daniel M. Green, MD, Member, Departments of Hematology-Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN; Nina Kadan-Lottick, MD, MSPH Associate Research Scientist, Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Lillian Meacham, MD, Medical Director, Cancer Survivor Program, Division of Pediatric Endocrinology, Children's Healthcare of Atlanta, Atlanta, GA; Anna T. Meadows, MD, Professor of Pediatrics, University of Pennsylvania School of Medicine, Director, Follow-Up Program, The Children's Hospital of Philadelphia, Philadelphia, PA, Joseph P. Neglia, MD, MPH, Professor of Pediatrics, Division of Hematology, Oncology, Blood and Marrow Transplantation, University of Minnesota School of Medicine, Minneapolis, MN; Kevin C. Oeffinger, MD, Director, Living Beyond Cancer Program, Memorial Sloan-Kettering Cancer Center, New York, NY; Leslie L. Robison, PhD, Chair, Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, MD, Director, Long-Term Follow-Up Program, Memorial Sloan Kettering Cancer Center; New York, NY, Julia Steinberger, MD, MS, Associate Professor, Division of Cardiology, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN

All Children's Oncology Group (COG) members have complied with the COG conflict of interest policy, which requires disclosure of any potential financial or other conflicting interests.

This is the current release of the guideline.

This guideline updates a previous version: Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Sections 107-132: surgery. In: Children's Oncology Group. Bethesda (MD): Children's Oncology Group; 2006 Mar. p. 26. [110 references]

Electronic copies: Available in Portable Document Format (PDF) from the Children's Oncology Group Web site .

The following are available:

• Instructions for use. Long-term follow-up guidelines. Version 3.0. Children's Oncology Group. 2008 Oct. 6 p.
• Introduction and explanation of scoring. Long-term follow-up guidelines. Version 3.0. Children's Oncology Group. 2008 Oct. 9 p.
• Summary of cancer treatment. Appendix I: Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Version 3.0. Children's Oncology Group. 2008 Oct.
• Patient-specific guideline identification tool. Appendix I: Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Version 3.0. Children's Oncology Group. 2008 Oct.
• Radiation reference guide. Appendix I: Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Version 3.0. Children's Oncology Group. 2008 Oct.

Electronic copies: Available in Portable Document Format (PDF) from the Children's Oncology Group Web site .

In an effort led by the Nursing Clinical Practice Subcommittee, complementary patient education materials (Health Links) were developed and are available in Appendix II of the original guideline document. The following Health Links are relevant to this summary:

Section 107

• Amputation 

Section 109

• Cystectomy 

Sections 109, 114

• Kidney Health 

Section 110

• Eye Health 

Sections 111, 123, 124

• Female Health Issues 

Section 112

• Gastrointestinal Health 

Section 113

• Limb Sparing Procedures 

Section 114

• Single Kidney Health 

Section 115

• Educational Issues 

Section 119

• Neurogenic Bladder 

Section 121, 125, 128

• Male Health Issues 

Section 130

• Pulmonary Health 

Section 131

• Splenic Precautions 

Section 132

• Thyroid Problems 

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI Institute on May 11, 2007. The information was verified by the guideline developer on June 11, 2007. This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This summary was updated by ECRI Institute on May 5, 2009, following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This NGC summary was updated by ECRI Institute on May 3, 2010. The updated information was verified by the guideline developer on July 13, 2010. This summary was updated by ECRI Institute on November 12, 2010 following the U.S. Food and Drug Administration (FDA) advisory on Afluria (influenza virus vaccine).

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.