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Raise your clinic's adult immunization rates

Standing Orders – A Solution to Missed Opportunities and Low Immunization Rates!

How Standing Orders Can Help

Standing orders streamline the delivery of adult immunizations by simplifying the process of identifying and vaccinating appropriate patients in your practice. By putting in place a routine, standardized process, such as a standing order, you empower your staff to assess and vaccinate patients according to current CDC recommendations, while you maintain overall control of the process.

Using standing orders (1) improves efficiency in delivering adult immunizations, and (2) increases overall adult immunization coverage rates, leading to improved patient health.

The Need For Standing Orders

Immunization rates for adults in the United States are unacceptably low: Influenza (49%), Tdap (17%), Zoster (24%).

As a result, more morbidity and mortality are associated with adult vaccine-preventable diseases (VPDs) than with pediatric VPDs, where stronger immunization efforts exist.

In a busy adult practice covering a broad range of services, delivery of adult immunizations can become an overlooked preventive intervention, despite the fact that full insurance coverage for patients up to 65 years of age is available under the Affordable Care Act.

Medical practices can help remedy this situation by implementing standing orders. These key practice components have been demonstrated to:

  • Streamline assessment of the need for and the administration of vaccines
  • Improve vaccine coverage rates in the practice
  • Improve patient care

Despite the endorsement of the use of standing orders by multiple major medical and public health organizations, these simple tools are not being implemented in many adult practices, leading to multiple missed opportunities to vaccinate patients and to prevent unnecessary disease and death.

What Immunization Leaders Say About Standing Orders

“The American Academy of Physician Assistants is deeply committed to increasing adult immunization rates and strongly supports the use of standing orders to administer vaccines to adults. In short, standing orders help PAs deploy their full skill set efficiently and effectively by reducing unneeded steps in clinic operations and capturing often missed opportunities to vaccinate.”

Marie-Michèle Léger, MPH, PA-C

Director, Clinical Education, American Academy of Physician Assistants (AAPA)

“Immunization of adults is a complex process, but attention and standardization of procedures via the use of standing orders in medical practices have demonstrated major impact on patient care. Using standing orders ensures that each patient will receive the best preventive care at every visit. Not by chance, but by design.”

Ruth Carrico, PhD, RN

Clinical Director, Vaccine and International Health and Travel Clinics

“Standing orders are one of the most effective and cost-effective methods to raise immunization rates. For standing orders to be most effective, a routine trigger is needed, such as vaccination as a vital sign.”

Richard K Zimmerman, MD, MPH

Professor, Department of Family Medicine, University of Pittsburgh

“Standing orders take the guesswork out of a crowded vaccine schedule. For a busy clinician, they can be the perfect failsafe.”

Paul A. Offit, MD

Chief of the Division of Infectious Diseases and Director of the Vaccine Education Center at the Children’s Hospital of Philadelphia

“At UnitedHealthcare, we encourage medical practices to implement standing orders because we know they increase vaccination rates.”

Dr. Richard Justman

National Medical Director, UnitedHealthcare

“Using standing orders for all routine vaccines is the key to improving immunization rates in a medical practice. Assessment of the vaccination status should be a part of the vital sign process for all patients. A clinic vaccine champion can manage unusual situations and ensure the correct application of all standing orders. Standing orders enable us to Vaccinate Today!”

Donald B. Middleton, MD

Professor of Family Medicine, University of Pittsburgh Medical Center St. Margaret

“Standing orders help to improve practice efficiency and enable standardization in vaccinating adult patients. The National Foundation for Infectious Diseases (NFID) supports the use of standing orders to increase vaccination rates among adults.”

William Schaffner, MD

NFID Medical Director

“Implementing standing orders in our practice helped eliminate the uncertainty that the clinical staff felt as to which vaccines should be given to which patients. Now clinical staff members are empowered to discuss vaccine status with patients and to administer the appropriate vaccines without delay or hesitation. This has allowed the entire office to play an integral part in increasing the number of adult patients who receive needed immunizations.”

Jo Ann Stadtfeld, RN, BSN

Practice Manager, Gordon Gold MD & Associates University of Pittsburgh Medical Center

Our Experts

Litjen (L.J) Tan, MS, PhD

Chief Strategy Officer

Immunization Action Coalition

L.J Tan is chief strategy officer for the Immunization Action Coalition (IAC), which he joined in January, 2013. Previously, Tan was director of medicine and public health at the American Medical Association (AMA) for 15 years.
Tan also serves as co-chair of the National Adult and Influenza Immunization Summit which is a joint project with IAC, the Centers for Disease Control and Prevention (CDC) and the National Vaccine Program Office (NVPO).
Tan recently served on the National Quality Forum’s Adult Immunizations Expert Committee and is currently a member of the Pharmacy Quality Alliance’s Adult Immunization Working Group and the European Society of Clinical Microbiology and Infectious Diseases Vaccine Study Group (EVASG). He is an editor of Journal for Disaster Medicine and Public Health Preparedness, BMC Infectious Diseases, and Medscape Infectious Diseases.
He just completed his term as an elected member of the federal National Vaccine Advisory Committee (NVAC) and continues to serve on NVAC’s HPV and Vaccine Confidence working groups. Tan has chaired NVAC’s Immunization Infrastructure Working Group and served on its Vaccine Safety Working Group.
Tan was a liaison member of CDC’s Advisory Committee for Immunization Practices (ACIP) for 12 years and currently serves on ACIP’s Adult Immunization Working Group. Previously, Tan was a member of the influenza, zoster, and evidence-based working groups of ACIP.

Deborah L. Wexler, MD

Founder and Exec. Director

Immunization Action Coalition

Dr. Deborah Wexler is founder and executive director of the Immunization Action Coalition (IAC). IAC’s mission is to increase immunization rates by providing the nation’s healthcare professionals and their patients with practical, concise, and up-to-date immunization information.
During the 1990–91 U.S. measles epidemic, Wexler, in her medical practice in Saint Paul, Minnesota, established her first standing orders protocols so that registered nurses could provide vaccination services on their own without a physician being present. Since then, she has guided IAC’s development of standing orders templates for 14 routinely recommended vaccines, along with standing orders for managing medical emergencies related to the vaccination of both children and adults. Under her leadership, IAC also publishes general guidance materials including Using Standing Orders for Administering Vaccines: What You Should Know. All IAC standing orders materials are freely available online at
Dr. Wexler’s educational background includes a bachelor of science degree in biology and an MD degree from the University of Minnesota. She completed her residency training in the Department of Family Practice and Community Health at the University of Wisconsin. Wexler serves on multiple national committees involved in vaccine policy and strategy issues. She is the recipient of the 2010 Friend of Pharmacy Immunization Leadership Award from the American Pharmacists Association and the 2011 National Childhood Immunization Champion award from Every Child By Two.

William Atkinson, MD, MPH

Assoc. Dir. Immunization Education

Immunization Action Coalition

Dr. William Atkinson is associate director for immunization education at the Immunization Action Coalition, which he joined in 2012. Atkinson attended the University of Missouri – Kansas City School of Medicine with postgraduate training in internal medicine, adult infectious diseases, and preventive medicine, receiving a master’s degree in public health from the Tulane University School of Public Health and Tropical Medicine.
For 25 years, Atkinson was a medical officer at the Centers for Disease Control and Prevention where he participated in a variety of immunization-related activities including measles surveillance and outbreak control, creation of technical and training materials for vaccine providers, and the development of national immunization policy. From 1995 through 2012, he was the writer, producer, and presenter for 125 national satellite broadcasts and webcasts on multiple vaccine-preventable disease topics. He is the recipient of numerous awards including the U.S. Public Health Service Distinguished Service medal.

Alexandra Stewart, JD

Assoc. Professor

Milken Inst. School of Public Health

Alexandra Stewart is an associate professor with the Milken Institute School of Public Health at the George Washington University in Washington, D.C. She is a graduate of Trinity College and the George Washington University Law School.
Stewart has worked with a variety of stakeholders, including the Centers for Disease Control and Prevention and the National Vaccine Program Office of the U.S. Department of Health and Human Services, conducting research and providing technical assistance to improve standards for immunization coverage and performance in children and adults.
She has examined the legal environment in the 50 states and the District of Columbia surrounding the use of standing orders for vaccine delivery. Her other research projects have focused on policy and access issues surrounding human papillomavirus vaccine, vaccination of U.S. health care personnel, the U.S. vaccine injury compensation program, vaccines and autism, immunization requirements for school and daycare entry, U.S. vaccine financing, public and private insurance coverage, and the impact of health reform initiatives on vaccine policy and practice. She also has drafted model statutes addressing state private insurance law for immunization coverage, establishment of and data sharing among state immunization information systems, and establishment of perinatal and infant hepatitis B testing and vaccination programs.

Litjen (L.J) Tan, MS, PhD

Deborah L. Wexler, MD

William Atkinson, MD, MPH

Alexandra Stewart, JD

Supporting Organizations

American College of Physicians

American Academy of Family Physicians

American Association of Nurse Practitioners

Association of Immunization Managers

Association of State and Territorial Health Officials

Gerontological Society of America

National Association of County and City Health Officials

National Foundation for Infectious Diseases (NFID)

Public Health Foundation

Society of Teachers of Family Medicine – Group on Immunization Education

Vaccine Education Center, Children’s Hospital of Philadelphia

Downloads To Share

Project Overview


Share Our Resources

All About Standing Orders


Tools and information from IAC and other organizations


Educational materials from the Immunization Action Coalition

Standing Orders Templates

Examples of Standing Orders protocols

Journal Articles

Selected journal articles on the use of Standing Orders

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