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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).


  1. National Center for Health Statistics. Early release of selected estimates from the 2002 National Health Interview Surveys. Available at
  2. 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.
  3. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18:92--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, Maryland: U.S. Department of Health and Human Services, Health Care Financing Administration, October 1999; HCFA publication no. HCFA-02151.
  5. Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-based strategies for improving influenza vaccination rates. J Fam Prac 1994;38: 258--61.
  6. 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.
  7. CDC. Use of standing orders programs to increase adult vaccination rates: recommendations of the Advisory Committee on Immunization Practices. MMWR 2000;49(No. RR-1).
  8. 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
  9. 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.
  10. 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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