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
CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 1997;46(No. RR-8).
CDC. Prevention and control of influenza: recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 1998;47(No. RR-6).
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.
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.
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.
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.
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.
Glezen WP, Couch RB. Interpandemic influenza in the Houston area, 1974-76. N Engl J
Med 1978;298:587-92.
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.
Barker WH, Mullooly JP. Impact of epidemic type A influenza in a defined adult
population. Am J Epidemiol 1980;112:798-813.
Glezen WP. Serious morbidity and mortality associated with influenza epidemics
[Review]. Epidemiol Rev 1982;4:25-44.
Gardner P, Schaffner W. Immunization of adults. N Engl J Med 1993;328:1252-8.
Hook EW III, Horton CA, Schaberg DR. Failure of intensive care unit support to
influence mortality from pneumococcal bacteremia. JAMA 1983;249:1055-7.
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.
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.
American Medical Association. Prevention of pneumococcal disease: use of
pneumococcal polysaccharide vaccine. Quality Care Alert 1999;2.
CDC. Missed opportunities for pneumococcal and influenza vaccination of
Medicare pneumonia inpatients--12 western states, 1995. MMWR 1997;46:919-23.
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.
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.
Nichol KL, Grimm MB, Petersen DC. Immunization in long-term care facilities: policies
and practice. J Am Geriatr Soc 1996;44:349-55.
Klein RE, Adachi N. An effective hospital-based pneumococcal immunization program.
Arch Intern Med 1986;146:327-9.
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.
Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates: nurse
protocols versus clinical reminders. J Gen Intern Med 1999;14:351-6.
Noe CA, Markson LJ. Pneumococcal vaccination: perceptions of primary-care
physicians. Prev Med 1998;27:767-72.
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.
CDC. Public health burden of vaccine-preventable diseases among adults: standards for
adult immunization practice. MMWR 1990;39:725-9.
Jackson LA, Benson P, Sneller V-P, et al. Safety of revaccination with
pneumococcal polysaccharide vaccine. JAMA 1999;281:243-8.
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.
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.
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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