Use of Standing Orders Programs to Increase Adult Vaccination Rates

Recommendations of the Advisory Committee on Immunization Practices

Advisory Committee on Immunization Practices Membership List, February 2000 

CHAIRMAN
John F. Modlin, M.D. 
Professor of Pediatrics and Medicine 
Dartmouth Medical School 
Lebanon, New Hampshire

EXECUTIVE SECRETARY
Dixie E. Snider, Jr., M.D., M.P.H. 
Associate Director for Science 
CDC 
Atlanta, Georgia 

MEMBERS  

Dennis A. Brooks, M.D., M.P.H. 
Johnson Medical Center 
Baltimore, Maryland

Richard D. Clover, M.D. 
University of Louisville School of Medicine 
Louisville, Kentucky

David W. Fleming, M.D. 
Oregon Health Division 
Portland, Oregon

Fernando A. Guerra, M.D., M.P.H. 
San Antonio Metropolitan Health District 
San Antonio, Texas

Charles M. Helms, M.D., Ph.D. 
University of Iowa Hospital and Clinics 
Iowa City, Iowa

David R. Johnson, M.D., M.P.H. 
Michigan Department of Community Health 
Lansing, Michigan

Chinh T. Le, M.D. 
Kaiser Permanente Medical Center 
Santa Rosa, California

Paul A. Offit, M.D. 
The Children's Hospital of Philadelphia 
Philadelphia, Pennsylvania

Margaret B. Rennels, M.D. 
University of Maryland School of Medicine 
Baltimore, Maryland

Lucy S. Tompkins, M.D., Ph.D. 
Stanford University Medical Center 
Stanford, California

Bonnie M. Word, M.D. 
State University of New York 
Stony Brook, New York

EX OFFICIO MEMBERS  

William Egan, Ph.D. 
Food and Drug Administration 
Rockville, Maryland

Geoffrey S. Evans, M.D. 
Health Resources and Services Administration 
Rockville, Maryland

Michael A. Gerber, M.D. 
National Institutes of Health 
Bethesda, Maryland

T. Randolph Graydon 
Health Care Financing Administration 
Baltimore, Maryland

Martin G. Meyers, M.D. 
National Vaccine Program Office, CDC 
Atlanta, Georgia

Kristin Lee Nichol, M.D., M.P.H. 
VA Medical Center 
Minneapolis, Minnesota

Douglas A. Thoroughman, Ph.D. 
Indian Health Service 
Albuquerque, New Mexico

David H. Trump, M.D., M.P.H. 
Office of the Assistant Secretary of Defense (Health Affairs) 
Falls Church, Virginia 

LIAISON REPRESENTATIVES 

American Academy of Family Physicians  
Richard Zimmerman, M.D. 
Pittsburg, Pennsylvania

American Academy of Pediatrics  
Larry Pickering, M.D. 
Atlanta, Georgia 
Jon Abramson, M.D. 
Winston-Salem, North Carolina

American Association of Health Plans  
Erik K. France, M.D. 
Denver, Colorado

American College of Obstetricians and Gynecologists  
Stanley A. Gall, M.D. 
Louisville, Kentucky

American College of Physicians  
Pierce Gardner, M.D. 
Stony Brook, New York

American Hospital Association  
William Schaffner, M.D. 
Nashville, Tennessee 

American Medical Association  
H. David Wilson, M.D. 
Grand Forks, North Dakota

Association of Teachers of Preventive Medicine  
W. Paul McKinney, M.D. 
Louisville, Kentucky

Biotechnology Industry Organization  
Yvonne E. McHugh, Ph.D. 
Emeryville, California

Canadian National Advisory Committee on Immunization  
Victor Marchessault, M.D. 
Cumberland, Ontario

Healthcare Infection Control Practices Advisory Committee  
Jane D. Siegel, M.D. 
Dallas, Texas

Infectious Diseases Society of America  
Samuel L. Katz, M.D. 
Durham, North Carolina

National Immunization Council and Child Health Program, Mexico  
Jose Ignacio Santos, M.D. 
Mexico City, Mexico

National Medical Association  
Rudolph E. Jackson, M.D. 
Atlanta, Georgia

National Vaccine Advisory Committee 
Georges Peter, M.D. 
Providence, Rhode Island

Pharmaceutical Research and Manufacturers of America  
Barbara J. Howe, M.D. 
Collegeville, Pennsylvania 

The following CDC staff members prepared this report:

Linda J. McKibben, M.D., M.P.H.
Paul V. Stange, M.P.H.
Division of Prevention Research and Analytic Methods
Epidemiology Program Office

Vishnu-Priya Sneller, M.B.B.S., Ph.D.
Raymond A. Strikas, M.D.
Epidemiology and Surveillance Division
Lance E. Rodewald, M.D.
Immunization Services Division
National Immunization Program

in collaboration with

Peter A. Briss, M.D.
Division of Prevention Research and Analytic Methods
Epidemiology Program Office 

Use of Standing Orders Programs to Increase Adult Vaccination Rates

Recommendations of the Advisory Committee on Immunization Practices

Summary

The Advisory Committee on Immunization Practices recognizes the need for evidence-based policy to improve the delivery and receipt of immunization services recommended for adults (i.e., persons aged >18 years). Two recent, systematic reviews of the health services research literature recommended standing orders programs as an effective organizational intervention to improve vaccination coverage rates among adults. This report briefly reviews the evidence on the effectiveness of standing orders programs, describes standards for program implementation, and recommends initiating these programs to improve immunization coverage in several traditional and nontraditional settings.

INTRODUCTION

Standing orders programs authorize nurses and pharmacists to administer vaccinations according to an institution- or physician-approved protocol without a physician's exam. These programs have documented improved vaccination rates among adults. Standing orders programs can be used in inpatient and outpatient facilities, long-term-care facilities, managed-care organizations, assisted living facilities, correctional facilities, pharmacies, adult workplaces, and home health-care agencies to vaccinate patient, client, resident, and employee populations. The Advisory Committee on Immunization Practices (ACIP) recommends standing orders for influenza and pneumococcal vaccinations (1,2). Recently, systematic literature reviews by the Task Force for Community Preventive Services (3) and the Southern California Evidence-Based Practice Center-RAND endorsed these programs for adult populations (4).

This report briefly reviews the evidence regarding the effectiveness of standing orders programs in improving adult vaccination coverage rates and recommends prioritizing these programs for influenza and pneumococcal vaccinations, to have the greatest impact on the burden of vaccine-preventable diseases in the United States. Standing orders programs are also recommended for other vaccines, including hepatitis B vaccine and diphtheria and tetanus toxoid vaccines, when feasible.

BACKGROUND

Epidemics of influenza occur during the winter months nearly every year and are responsible for an average of approximately 20,000 deaths per year in the United States (5,6). Influenza viruses cause disease in all age groups (7,8), but rates of serious morbidity and mortality are highest among persons aged >65 years and persons of any age who have medical conditions that place them at high risk for complications from influenza (2,9-11). Pneumococcal disease accounts for approximately 3,000 cases of meningitis, 50,000 cases of bacteremia, and 500,000 cases of pneumonia each year (1) and is responsible for more deaths than any other vaccine-preventable bacterial disease (12). Despite antimicrobial therapy and intensive medical care, the overall case-fatality rate for pneumococcal bacteremia is 15%-20% among adults (i.e., persons aged >18 years) (1). Among persons aged >65 years, case-fatality rates can be as high as 40% (13).

In recent years, a rapid emergence of antimicrobial resistance among pneumococci, especially to penicillin, has occurred. Increasing pneumococcal vaccination rates could help prevent invasive pneumococcal disease caused by vaccine-type, multidrug- resistant pneumococci. Outbreaks of pneumococcal disease caused by a single drug-resistant pneumococcal serotype have occurred in institutional settings, including nursing homes (14,15). In 1999, because of concerns about pneumococcal antimicrobial resistance and underuse of pneumococcal vaccine, the American Medical Association and several partner organizations issued a Quality Care Alert that supports ACIP's recommendations for pneumococcal vaccination (16).

Health services research indicates that influenza and pneumococcal vaccines are underused in institutional settings, even after they became covered benefits of Medicare Part B (1981 for pneumoccocal vaccine and 1993 for influenza vaccine) (17,18). Despite the availability of suitable vaccines, persons hospitalized with conditions for which influenza and pneumococcal vaccines are indicated are not usually assessed for vaccination status or vaccinated. Among persons who reported at least one hospitalization during the preceding year to the 1997 National Health Interview Survey, 83% of persons aged 18-64 years with medical conditions that put them at high risk and 55% of all persons aged >65 years reported not receiving pneumococcal vaccinations (CDC, unpublished data, 1999). Sixty-nine percent of persons aged 18-64 years with medical conditions that put them at high risk and 32% of all persons aged >65 years reported not receiving influenza vaccination (CDC, unpublished data, 1999). In 12 western states, 80% of Medicare beneficiaries hospitalized for pneumonia during September-December 1994 did not receive influenza vaccines; 65% did not receive pneumococcal vaccines (17). The 1995 National Nursing Home Survey estimated influenza and pneumococcal vaccination rates among residents in long-term-care facilities to be approximately 63% and 22%, respectively (18). These rates are far below the Healthy People 2010 objective of 90% for both vaccines among all persons aged >65 years (objective 14-29) (19). Coverage estimates for 1997 were approximately 64% for influenza vaccines and 28% for pneumococcal vaccines (CDC, unpublished data, 1999). Many long-term-care facilities have inadequate policies and procedures to prevent vaccine-preventable diseases among their vulnerable populations (20).

Several studies suggest that standing orders programs are more effective than other institution-based strategies in improving vaccination services. In one New York hospital, instituting a standing orders program for pneumococcal vaccination among persons aged >65 years and other patients at high risk increased the pneumococcal vaccination rate from 0% to 78% (21). In another study, pharmacists increased pneumococcal vaccination rates from 4.2% to 94% in one nursing facility and from 1.9% to 83% in a second facility, whereas the rates at a control facility increased from 0.9% to 4.0% (22). In a study of six small community hospitals in northern Minnesota, standing orders programs achieved an influenza vaccination rate of 40.3% among patients, compared with 17% using physician reminders and 9.6% using educational programs (23). A study conducted in an ambulatory care clinic compared the use of nurse standing orders combined with other interventions, including patient and health-care provider reminders, with the use of patient and provider reminders alone. Pneumococcal vaccination rates per total patient population were 22%-25% for the nurse standing orders programs, compared with 5% when patient and provider reminders were used alone (24).

Based on the scientific evidence of effectiveness in improving vaccination rates in institutions, the Task Force for Community Preventive Services and the Southern California Evidence-Based Practice Center-RAND recommend standing orders programs for the vaccination of adults in hospitals, clinics, and nursing homes (3,4). Standing orders policies are acceptable to most primary-care physicians (25) and have resulted in higher vaccination rates than other vaccination delivery methods (4,26).

IMPLEMENTATION GUIDELINES

Successful standing orders programs begin by documenting a plan for the program's infrastructure, key service-delivery components, and quality assurance. To ensure success, a committee should be formed that includes the organization's medical director, nursing director, infection-control and quality-control personnel, and medical or nursing staff representatives. This committee should write protocols for the following procedures:

• Identifying persons eligible for vaccination based on their age, their vaccination status (e.g., persons previously unvaccinated or due for vaccination according to the recommended schedule), or the presence of a medical condition that puts them at high risk.
• Providing adequate information to patients or their guardians regarding the risks for and benefits of a vaccine and documenting the delivery of that information.
• Recording patient refusals or medical contraindications.
• Recording administration of a vaccine(s) and any postvaccination adverse events, according to institution- or physician-approved protocol.
• Providing documentation of vaccine administration to patients and their primary-care providers.

Standing orders protocols should also specify that vaccines be administered by health-care professionals trained to a) screen patients for contraindications to vaccination, b) administer vaccines, and c) monitor patients for adverse events, in accordance with state and local regulations. Vaccine information statements developed by and available from CDC can be useful for risk/benefit counseling before administering a vaccine. All health-care personnel administering vaccines or providing care to vaccinated persons should be trained to report adverse outcomes to the Vaccine Adverse Events Reporting System (VAERS). The appropriate VAERS forms and contact information should be readily available in all facilities delivering vaccines.

The standards for adult immunization practice established by the National Coalition for Adult Immunization recommend that standing orders programs include a standard personal and institutional immunization record to verify the immunization status of patients and staff members and to reduce the risk for inappropriate revaccination (27). A patient's primary-care provider should be able to override institutional standing orders when medically appropriate. Ongoing communication between the primary-care provider, vaccinee, and institutional staff members is recommended to reduce the possibility of inappropriate vaccinations.

None of the studies of standing orders programs for influenza and pneumococcal vaccination reported unnecessary or inappropriate vaccinations (3,4,21-23,26). If repeated pneumococcal vaccinations did occur, studies have indicated that the risk for adverse events beyond self-limited local reactions was minimal for a second dose administered 2-5 years after the primary dose (1,28). The risk for self-limited local injection site reactions does not represent a contraindication to revaccination with pneumococcal vaccine in recommended groups.

The policies and protocols for standing orders programs should include a quality assurance process to maintain appropriate standards of care. The feasibility and cost- effectiveness of standing orders programs in several settings need ongoing evaluation, with particular attention to safety and tracking of vaccinations (29). For example, preprinted admissions orders could improve the effectiveness of program staff members to assess the vaccination status of patients and to provide information about the risks for and benefits of administering vaccinations routinely upon admission to facilities.

Facility staff members should consider other potential benefits (e.g., sustainability over time) when developing standing orders programs (30). These programs could be adapted to other preventive services (e.g., mammography) to improve delivery of those services, and they could be used to improve clinic efficiency by reducing pressures on physicians' time (3).

CONCLUSION

ACIP recommends that standing orders programs be used in long-term-care facilities under the supervision of a medical director to ensure the administration of recommended vaccinations for adults. ACIP also encourages the introduction of standing orders programs for vaccination of adults in other settings (e.g., inpatient and outpatient facilities, managed-care organizations, assisted living facilities, correctional facilities, pharmacies, adult workplaces, and home health-care agencies). Implementation of standing orders programs alone or combined with other effective interventions can help improve vaccination coverage by institutional providers (3,4,31). Because of the societal burden of influenza and pneumococcal disease, implementation of standing orders programs to improve adult vaccination coverage for these diseases should be a national public health priority.

References

1. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(No. RR-8).
2. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(No. RR-6).
3. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18(suppl):92-140.
4. 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, MD: US Department of Health and Human Services, Health Care Financing Administration, October 1999; HCFA publication no. HCFA-02151.
5. Simonsen L, Schonberger LB, Stroup DF, Arden NH, Cox NJ. The impact of influenza on mortality in the USA. In: Brown LE, Hampson AW, Webster RG, eds. Options for the control of influenza III. Amsterdam: Elsevier Science BV, 1996:26-33.
6. Lui K-J, Kendal AP. Impact of influenza epidemics on mortality in the United States from October 1972 to May 1985. Am J Public Health 1987;77:712-6.
7. Monto AS, Kioumehr F. The Tecumseh study of respiratory illness. IX. Occurrence of influenza in the community, 1966-1971. Am J Epidemiol 1975;102:553-63.
8. Glezen WP, Couch RB. Interpandemic influenza in the Houston area, 1974-76. N Engl J Med 1978;298:587-92.
9. Barker WH. Excess pneumonia and influenza associated hospitalization during influenza epidemics in the United States, 1970-78. Am J Public Health 1986;76:761-5.
10. Barker WH, Mullooly JP. Impact of epidemic type A influenza in a defined adult population. Am J Epidemiol 1980;112:798-813.
11. Glezen WP. Serious morbidity and mortality associated with influenza epidemics [Review]. Epidemiol Rev 1982;4:25-44.
12. Gardner P, Schaffner W. Immunization of adults. N Engl J Med 1993;328:1252-8.
13. Hook EW III, Horton CA, Schaberg DR. Failure of intensive care unit support to influence mortality from pneumococcal bacteremia. JAMA 1983;249:1055-7.
14. Quick RE, Hoge CW, Hamilton DJ, Whitney CJ, Borges M, Kobayashi JM. Underutilization of pneumococcal vaccine in nursing homes in Washington state: report of a serotype-specific outbreak and a survey. Am J Med 1993;94:149-52.
15. CDC. Outbreaks of pneumococcal pneumonia among unvaccinated residents in chronic-care facilities--Massachusetts, October 1995, Oklahoma, February 1996, and Maryland, May-June 1996. MMWR 1997;46:60-2.
16. American Medical Association. Prevention of pneumococcal disease: use of pneumococcal polysaccharide vaccine. Quality Care Alert 1999;2.
17. CDC. Missed opportunities for pneumococcal and influenza vaccination of Medicare pneumonia inpatients--12 western states, 1995. MMWR 1997;46:919-23.
18. Greby SM, Singleton JA, Sneller V-P, Strikas RA, Williams WW. Influenza and pneumococcal vaccination coverage in nursing homes, U.S., 1995 [Abstract]. In: Abstracts of the 32nd National Immunization Conference. Atlanta, GA: CDC, National Immunization Program, 1998.
19. US Department of Health and Human Services. Healthy people 2010: conference edition--volume 1. Washington, DC: US Department of Health and Human Services, January 2000.
20. Nichol KL, Grimm MB, Petersen DC. Immunization in long-term care facilities: policies and practice. J Am Geriatr Soc 1996;44:349-55.
21. Klein RE, Adachi N. An effective hospital-based pneumococcal immunization program. Arch Intern Med 1986;146:327-9.
22. Morton MR, Spruill WJ, Cooper JW. Pharmacist impact on pneumococcal vaccination rates in long-term care facilities [Letter]. Am J Hosp Pharm 1988;45:73.
23. Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-based strategies for improving influenza vaccination rates. J Fam Pract 1994;38:258-61.
24. Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates: nurse protocols versus clinical reminders. J Gen Intern Med 1999;14:351-6.
25. Noe CA, Markson LJ. Pneumococcal vaccination: perceptions of primary-care physicians. Prev Med 1998;27:767-72.
26. Gyorkos TW, Tannenbaum TN, Abrahamowicz M, et al. Evaluation of the effectiveness of immunization delivery methods. Can J Public Health 1994;85(suppl):S14-S30. 
27. CDC. Public health burden of vaccine-preventable diseases among adults: standards for adult immunization practice. MMWR 1990;39:725-9.
28. Jackson LA, Benson P, Sneller V-P, et al. Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA 1999;281:243-8.
29. CDC. Adult immunization programs in nontraditional settings: quality standards and guidance for program evaluation--a report of the National Vaccine Advisory Committee. MMWR 2000;49(No. RR-1):1-14.
30. Nichol KL. Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. Am J Med 1998;105:385-92.
31. CDC. Recommendations of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians: use of reminder and recall by vaccination providers to increase vaccination rates. MMWR 1998;47:715-7.

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