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Notice to Readers: Facilitating Influenza and Pneumococcal
Vaccination Through Standing Orders Programs
Influenza and pneumococcal vaccines are underused for persons in the United States aged >65 years (66% receive influenza vaccine and 55% pneumococcal vaccine) (1), even among patients in nursing homes (68% for influenza and
38% for pneumococcal vaccine) (2). Systematic literature reviews by the Task Force on Community Preventive Services and
the Southern California Evidence-Based Practice Center-RAND have shown that standing orders programs improve
vaccination rates (3,4). Standing orders programs authorize nurses and pharmacists, where allowed by state law, to administer vaccinations according to an institution- or
physician-approved protocol without the need for a physician's examination or direct
order. Several studies have shown improved influenza and pneumococcal vaccination rates through standing orders
programs specifically in long-term care facilities (LTCFs) and hospitals
(5,6). Based on the strength of available evidence, the
Advisory Committee on Immunization Practices recommends the use of standing orders programs in both outpatient and
inpatient settings (7).
As a result of this recommendation, on October 2, 2002, the Centers for Medicare and Medicaid published an interim
final rule (8) that removes the physician signature requirement for influenza and pneumococcal vaccinations from the Conditions of Participation for Medicare and Medicaid participating hospitals, LTCFs, and home health agencies (HHAs).
The Conditions of Participation for these types of facilities require orders for drugs and biologicals to be in writing and signed by the practitioner(s) responsible for the care of the patient, with the exception of influenza and pneumococcal
polysaccharide vaccines, which can be administered per physician-approved facility or agency policy after an
assessment for contraindications. State agencies should be
informed about this change so that appropriate policy
revisions can be implemented (9).
This modification will improve access to influenza and pneumococcal vaccination in hospitals, LTCFs, and HHAs
as allowed by state law, consistent with standing orders programs already allowed in community and physician's outpatient office settings. If implemented rapidly, this change will facilitate achievement of the national health objective for 2010 of vaccinating at least 90% of the institutionalized and noninstitutionalized population aged
>65 years (10).
Buikema AR, Singleton JA, Sneller VP, Strikas RA. Influenza and pneumococcal vaccination in nursing homes, U.S., 1995--1999.
[Abstract]. Presented at the 35th National Immunization Conference. Atlanta, Georgia; 2001.
Task Force on Community Preventive Services. Recommendations
regarding interventions to improve vaccination coverage in children,
adolescents, and adults. Am J Prev Med 2000;18:92--140.
Health Care Financing Administration. Evidence report and evidence-based recommendations: interventions that increase the utilization
of Medicare-funded preventive service for persons age 65 and older.
Baltimore, Maryland: U.S. Department of Health and Human
Services, Health Care Financing Administration, October 1999; HCFA publication no. HCFA-02151.
Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-based strategies for improving influenza vaccination rates. J Fam Prac 1994;38: 258--61.
Stevenson KB, McMahon JW, Harris J, Hilman JR, Helgerson SD.
Increasing pneumococcal vaccination rates among residents of
long-term-care facilities: provider-based improvement strategies implemented by peer-review organizations in four western states. Infect Control Hosp Epidemiol 2000;21:705--10.
Centers for Medicare and Medicaid Services. Medicare and Medicaid programs: conditions of participation: immunization standards for
hospitals, long-term care facilities, and home health agencies. Washington, DC: U.S. Department of Health and Human Services, Centers for Medicare
and Medicaid Services, 2002. Available at
http://www.cms.gov/providerupdate/regs/cms3160fc.pdf.
Centers for Medicare and Medicaid Services, Center for Medicaid and State Operations. Program memorandum: change in requirement for
signed physician's order for influenza and pneumonia vaccine.
Washington, DC: U.S. Department of Health and Human Services, Centers for
Medicare and Medicaid Services, 2002; publication no. S&C-03-02.
U.S Department of Health and Human Services. Healthy people 2010, 2nd ed. With understanding and improving health and
objectives for improving health (2 vols). Washington, DC: U.S.
Department of Health and Human Services, 2000.
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Health and Human Services.References to non-CDC sites on the Internet are
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Department of Health and Human Services. CDC is not responsible for the content
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