Changes

November 2024 — reviewed. A literature search was conducted in October 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic title has been changed from Glandular fever (infectious mononucleosis) to Infectious mononucleosis (glandular fever), to reflect common terminology in the literature. The age cut-off below which to arrange Epstein-Barr virus (EBV) serology testing in children has been changed from 12 years to 4 years, in line with the Public Health England publication UK Standards for microbiology investigations. Epstein-Barr virus serology (PHE 2019). The information on treatments which are not recommended have been removed from the Management section. 

Update

Goals

To support primary healthcare professionals to:

• Make an accurate diagnosis of infectious mononucleosis.
• Provide appropriate self-management advice.
• Arrange hospital admission or seek specialist advice if a serious complication is suspected.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

What is it?

• Infectious mononucleosis (glandular fever) is an infection characterized by sore throat, fever, and lymphadenopathy, most commonly caused by Epstein-Barr virus (EBV) [Balfour, 2015; Fugl, 2019]. 
  • EBV (also known as the human herpesvirus 4) is one of the most common human viruses [Womack, 2015]. It causes approximately 80–90% of cases of infectious mononucleosis [Lennon, 2015; Fugl, 2019; BMJ Best Practice, 2021].
  • The term 'mononucleosis-like illness' is often used if symptoms are caused by a non-EBV aetiology, such as cytomegalovirus (CMV), human herpesvirus 6, toxoplasmosis, HIV, or adenovirus [Lennon, 2015; Fugl, 2019; BMJ Best Practice, 2021].

How is it transmitted?

• Epstein-Barr virus (EBV) transmission is primarily through close contact with the saliva of a person who is infected [Sylvester, 2023].
  • It is usually spread through contact with asymptomatic carriers, such as through kissing or sharing utensils [Lennon, 2015; Balfour, 2015; Sylvester, 2023]. It can also more rarely spread during sexual contact, blood transfusion, solid organ transplantation, or intrauterine vertical transmission [Rogers, 2012; Balfour, 2015; Dunmire, 2015; BMJ Best Practice, 2021; Sylvester, 2023].
  • The incubation period between exposure and symptom onset of EBV infection is about 4–7 weeks, which may make identifying the initial exposure challenging [Rogers, 2012; Lennon, 2015]. Expert opinion in a review article notes that EBV infection results in infectious mononucleosis in up to 74% of young adults [Womack, 2015]. The person is contagious during the incubation period and while symptoms are present [Sylvester, 2023]. Viral replication first occurs in the oropharynx followed by viraemia as early as 2 weeks before the onset of symptoms [Balfour, 2015]. Some people may be contagious for 5 months or more after acute infection [Fugl, 2019].
  • Young children probably acquire the virus from asymptomatic carers or siblings who shed low levels of EBV in their oral secretions and transmit a smaller infectious inoculum [Balfour, 2015; Dunmire, 2015].
• EBV infection leads to a lifelong latent carrier state by integrating into the life cycle of healthy B lymphocytes [Lennon, 2015].
  • There is persistent low-grade replication, and the virus is shed intermittently into pharyngeal secretions, particularly saliva. These low concentrations of infectious virus account for the low-to-moderate contagiousness of the disease and the need for intimate contact for disease transmission [Lennon, 2015].

How common is it?

Epidemiological studies show that over 95% of adults worldwide have been infected with Epstein-Barr virus (EBV) at some point during their lifetime [Balfour, 2015; Lennon, 2015; Womack, 2015]. The majority of these adults have had asymptomatic or subclinical infections [Rogers, 2012].

• Acute infectious mononucleosis is most common in people aged 15–24 years, although cases have been reported in all age groups [Womack, 2015] [BMJ Best Practice, 2021].
  • It is more likely to affect people who acquire primary EBV in their teenage years. In young adults, the rate of developing acute infectious mononucleosis from primary EBV infection is estimated at 50% (ranging between 26–74%). In older adults, EBV infection often does not progress to cause infectious mononucleosis [Womack, 2015].
  • The annual incidence in the general population is about 5 cases per 1000 people [Womack, 2015]. In settings with a large young adult population in close proximity, such as university student accommodation or military barracks, the annual incidence can be 11–48 cases per 1000 people [Ebell, 2004].
  • The annual incidence in people younger than 10 years, or older than 30 years, is less than 1 case per 1000 people [Ebell, 2004].
  • Infectious mononucleosis is rare during the first year of life because of passive immunity received from maternal antibodies [Womack, 2015].
• A population-based study conducted in Minnesota, USA identified all serologically-confirmed cases of infectious mononucleosis (n = 1818) between 1950 and 1969, and found [Henke, 1973]:
  • The annual incidence in people aged 15 to 19 years was 2.7%, among those aged 20 to 24 years was 1.3%, and among all other age groups, it was 0.2% or lower.
• There is no seasonal variation or sex predisposition in the incidence of infectious mononucleosis [Ebell, 2004] [Balfour, 2015] [Womack, 2015].

What are the complications?

• Serious complications during the acute phase of primary Epstein-Barr virus (EBV) infection are rare [Balfour, 2015]. People who are immunosuppressed are at higher risk of severe disease and possible complications: 
  • Hepatic — hepatitis is a common and self-limiting early complication, which rarely progresses to chronic hepatitis [Fugl, 2019]. Hepatitis occurs in 75% of people, but is usually subclinical (elevation of alanine aminotransferase levels without jaundice or abdominal pain) [Balfour, 2015]. 5–10% of people may present with jaundice [Fugl, 2019]. Fulminant or necrotic hepatitis may rarely occur and can be life-threatening [Rogers, 2012; Fugl, 2019]. See the CKS topic on Jaundice in adults for more information.
  • Upper airways— infection may cause severe tonsillar hypertrophy or a peritonsillar abscess (quinsy) [Rogers, 2012]. This may rarely lead to upper airway obstruction, stridor, and respiratory distress (more common in younger children with palatal and nasopharyngeal tonsillar hypertrophy) [Balfour, 2015; Womack, 2015; Fugl, 2019]. See the CKS topic on Sore throat - acute for more information.
  • Cardiac — pericarditis, myocarditis, and cardiac conduction abnormalities have been reported [Ebell, 2004; Lennon, 2015; Womack, 2015].
  • Renal — acute interstitial nephritis, myositis-associated acute kidney injury (AKI), haemolytic uraemic syndrome, and jaundice-associated nephropathy are rare [Ebell, 2004; Womack, 2015]. See the CKS topics on Acute kidney injury and Jaundice in adults for more information.
  • Neurological — meningoencephalitis occurs in about 1% of young people and adults, usually during the first 2 weeks of infection. Other possible complications include aseptic meningitis, facial nerve palsy, transverse myelitis, Guillain-Barré syndrome, seizures, sudden sensorineural hearing loss, and optic neuritis [Balfour, 2015; Lennon, 2015; Womack, 2015]. See the CKS topics on Meningitis - bacterial meningitis and meningococcal disease and Hearing loss in adults for more information.
  • Haematological — mild thrombocytopenia and autoimmune haemolytic anaemia have been reported. Mild neutropenia is common and self-limiting. Rarely, severe neutropenia may cause neutropenic sepsis, pneumonia, or death [Balfour, 2015; Lennon, 2015; Womack, 2015]. See the CKS topics on Chest infections - adult and Neutropenic sepsis for more information.
  • Splenic rupture — this is a rare complication due to splenomegaly which affects less than 1% of cases. It usually occurs within the first 3 weeks of acute illness, and most cases resolve by 4–6 weeks [Lennon, 2015]. It is more often spontaneous than traumatic, and is potentially life-threatening [Rogers, 2012; Womack, 2015; Fugl, 2019; Sylvester, 2023].
  • Chronic fatigue — up to 10% of people experience prolonged fatigue, lasting for months or more after initial infection. Prolonged symptoms may result in difficulty returning to school, work, or physical activities [Rogers, 2012]. Most people with persistent fatigue recover within 2 years [Lennon, 2015]. See the CKS topic on Tiredness/fatigue in adults for more information.
  • Multiple sclerosis — EBV infection may be a risk factor for developing multiple sclerosis, in addition to possible genetic susceptibility as well as the timing of infection. CKS notes there is controversy in the literature as to whether this is a true causal association [Balfour, 2015; Lennon, 2015; Fugl, 2019]. See the CKS topic on Multiple sclerosis for more information.
  • Chronic active EBV infection — a very rare condition characterized by severe, chronic, or recurrent infectious mononucleosis-like symptoms persisting for more than 3 months after a well-documented primary infection with EBV, which is associated with an increased risk of developing lymphoproliferative conditions [Lennon, 2015; Fugl, 2019].
  • Lymphoproliferative cancers — potential late-onset complications, especially Hodgkin's lymphoma and Burkitt lymphoma (an aggressive non-Hodgkin B-cell lymphoma), and nasopharyngeal carcinoma [Balfour, 2015; Dunmire, 2015; Fugl, 2019; Sylvester, 2023]. EBV is considered the aetiologic agent in 95% of cases of endemic Burkitt lymphoma, which occur in regions where malaria is common. EBV can be detected in a high proportion of Hodgkin's lymphoma cases in underdeveloped countries, but accounts for less than 50% of cases in developed countries [Dunmire, 2015]. See the CKS topic on Haematological cancers - recognition and referral for more information.

What is the prognosis?

In most people, infectious mononucleosis is a self-limiting illness lasting 2–4 weeks [Lennon, 2015].

• Occasionally the disease course can be prolonged, lasting for weeks or months [Sylvester, 2023].
  • 20% of people may have persistent sore throat one month after acute infection [Lennon, 2015].
  • Fatigue is common and usually lasts for a few weeks, but may persist for a year or more in 10% of people. Most people with persistent fatigue recover within 2 years [Fugl, 2019].
• A prospective population-based cohort study of people aged 16 years and older with confirmed acute Epstein-Barr virus (EBV) infection (n = 150) with a follow-up period of 6 months found [Rea, 2001]:
  • Symptoms of sore throat, fever, headache, rash, cough, and nausea had largely resolved after one month.
  • Symptoms of fatigue and hypersomnia improved more slowly over 2–6 months.
  • The majority of participants had returned to their usual level of functioning after 2 months.
• EBV infection leads to a lifelong latent carrier state [Lennon, 2015].
  • The virus may reactivate but does not always cause symptoms. People who are immunocompromised are more likely to develop symptoms if EBV reactivates [Lennon, 2015].

When should I suspect a diagnosis of infectious mononucleosis?

• Suspect a diagnosis of infectious mononucleosis, particularly in an adolescent or young adult, if a person presents with an acute illness characterized by fever, cervical lymphadenopathy, and/or sore throat.
  • Fever is usually low-grade. See the CKS topic on Feverish children - risk assessment and management for more information.
  • Cervical lymphadenopathy. 
    • Bilateral posterior cervical lymphadenopathy is typical, but a person may present with anterior involvement. There may also be submandibular, suboccipital, postauricular, epitrochlear, axillary, and inguinal lymphadenopathy.
    • Lymphadenopathy may persist for at least 3 weeks.
  • Sore throat (usually severe).
    • There may be tonsillar enlargement and a 'whitewash' exudate on the tonsils.
    • Pharyngeal inflammation and transient palatal petechiae are also common.
• Other clinical features that may support a diagnosis of infectious mononucleosis include:
  • Prodromal symptoms — usually last for several days, including general malaise, fatigue, myalgia, chills, sweats, anorexia, and headache.
  • Rash — typically a fine, diffuse maculopapular rash, but may be urticarial or petechial (rash usually presents after treatment with amoxicillin for presumed streptococcal pharyngitis).
  • Splenomegaly — the spleen reaches maximum size at the beginning of the second week of illness and typically regresses over 7–10 days.
  • Hepatomegaly — may be suggested by tenderness in the right upper quadrant.
• When considering a diagnosis of infectious mononucleosis, be aware that:
  • In young children, infection with Epstein-Barr virus (EBV) is usually asymptomatic or presents with non-specific symptoms which may be indistinguishable from other childhood viral illnesses. See the section on Differential diagnosis for more information.
  • In people older than 40 years of age, acute infection is rare and it may present atypically without sore throat and lymphadenopathy, but with hepatomegaly and jaundice. See the CKS topic on Jaundice in adults for more information.

How should I assess a person with suspected infectious mononucleosis?

If a person has suspected diagnosis of infectious mononucleosis:

• Ask about:
  • Symptoms, their onset, duration, and severity.
  • Any symptoms of a possible complication.
  • Any known infectious contact(s); any recent travel and sexual history.
  • Any known cause of underlying immunosuppression or immunocompromise (increased risk of severe disease and complications).
  • Usual physical activity levels and any involvement in contact or collision sports.
• Examine the person, assessing for signs of:
  • Fever, dehydration, respiratory compromise, and jaundice.
  • Any lymphadenopathy.
  • Pharyngeal inflammation; tonsillar enlargement and/or exudate; and palatal petechiae.
  • Any rash.
  • Upper abdominal pain and/or hepatosplenomegaly.
• In children younger than 4 years of age, and in people who are immunocompromised at any age:
  • Arrange blood tests for Epstein-Barr virus (EBV) serology after the person has been unwell for at least 7 days.
• In children older than 4 years of age, and in immunocompetent adults:
  • Arrange a full blood count (FBC) with differential white cell count and a heterophile antibody (monospot) test in the second week of illness.
    • Infectious mononucleosis is likely if the monospot test is positive or the FBC has more than 20% atypical or 'reactive' lymphocytes, or more than 10% atypical lymphocytes and the lymphocyte count is more than 50% of the total white cell count (part of the so-called 'Hoagland criteria').
  • If the monospot test is negative or not supportive of a diagnosis of infectious mononucleosis due to EBV, repeat the test in 5–7 days.
    • If the person has clinical features of infectious mononucleosis and a negative monospot test, or if a rapid diagnosis is needed (for example to allow an urgent return to contact or collision sports in a competitive athlete), arrange blood tests for specific EBV serology (such as viral capsid antigen IgM and IgG antibody testing).
  • If the second monospot test or specific EBV serology is negative and confirmation of the diagnosis is needed:
    • Consider testing for cytomegalovirus (CMV), HIV, and toxoplasmosis if the person is pregnant, immunocompromised, and/or at risk of HIV infection. See the CKS topic on HIV infection and AIDS for more information.
• If there are severe symptoms or a suspected liver complication, consider checking liver function tests (LFTs), depending on clinical judgement.
  • Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) may be elevated to 2–3 times the upper limit of normal during the acute phase of infection, and subsequently normalize within about 3 weeks in most people.

What else might it be?

Other conditions which may present similarly to infectious mononucleosis include:

• Other causes of sore throat (such as streptococcus) — lymphadenopathy is usually anterior cervical and submandibular, with no hepatosplenomegaly, and fatigue may be less prominent. Viral sore throat due to rhinovirus, adenovirus, or coronavirus, for example, may also cause similar symptoms. See the CKS topics on Sore throat - acute, Common cold, and Coronavirus - COVID-19 for more information.
• Other causes of lymphadenopathy, such as:
  • Local infection or inflammation.
  • Head and neck cancer. See the CKS topic on Head and neck cancers - recognition and referral for more information.
  • Haematological cancer, such as lymphoma or acute leukaemia (the latter rarely presents with lymphadenopathy). See the CKS topic on Haematological cancers - recognition and referral for more information.
• Other viral infections that may present with an infectious mononucleosis-like illness with an atypical lymphocytosis, such as:
  • Cytomegalovirus (CMV) primary infection — may present with splenomegaly, hepatomegaly, and a negative monospot test. Sore throat and lymphadenopathy are rare.
  • Acute toxoplasmosis — lymphocytosis is mild, but there may be hepatomegaly or splenomegaly.
  • Acute viral hepatitis — may cause malaise, fever, lymphadenopathy, and atypical lymphocytosis. Usually, the lymphocytes are less than 10% of the total white cell count and liver function tests (LFTs) are markedly elevated. See the CKS topics on Hepatitis A, Hepatitis B, and Hepatitis C for more information.
  • Primary HIV infection — may present with pharyngitis, fever, lymphadenopathy, rash, diarrhoea, weight loss, nausea, and vomiting. Mononucleosis-like illness is an HIV indicator condition. See the CKS topic on HIV infection and AIDS for more information.
  • Rubella — may rarely present with fever, lymphadenopathy, and atypical lymphocytosis. See the CKS topic on Rubella for more information.
  • Roseola (human herpes virus-6 primary infection) — is usually mild with a modest atypical lymphocytosis.
  • Measles — typically presents with a high-grade fever, maculopapular rash spreading from the face downwards, coryza, cough, and/or conjunctivitis. See the CKS topic on Measles for more information.
  • Mumps — typically presents with parotitis, low-grade fever, and malaise. See the CKS topic on Mumps for more information.
  • Herpes simplex virus-1 — may present with a prodrome of fever, sore throat, and lymphadenopathy, particularly in primary infections. See the CKS topic on Herpes simplex - oral for more information.
  • Influenza — typically presents with acute onset of high-grade fever, cough, and myalgia, with symptoms typically lasting less than 2 weeks. Posterior cervical lymphadenopathy is usually absent. See the CKS topic on Influenza - seasonal for more information.

Scenario: Management of infectious mononucleosis

From age 1 month onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of glandular fever.

Search dates

January 2020 - October 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 24th September 2019, update searches completed 28/01/2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases.

S8    S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 
S7    AB EBV OR TI EBV 
S6    AB epstein-barr virus OR TI epstein-barr virus 
S5    AB glandular fever OR TI glandular fever 
S4    AB infectious mononucleosis OR TI infectious mononucleosis 
S3    (MH "Herpesvirus 4, Human") 
S2    (MH "Epstein-Barr Virus Infections+") 
S1    (MH "Infectious Mononucleosis") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.