Acceptance of Pneumococcal Vaccine
under Standing Orders by Race and Ethnicity
Nicholas A. Daniels, MD, MPH; Susan Gouveia, RN; Daniel Null, MD; Ginny L. Gildengorin, PhD; and
Carla A. Winston, PhD, MA
San Francisco, California and Atlanta, Georgia
The findings and conclusions in this report are those of the
author(s) and do not necessary represent the views of the
Purpose: To assess whether and how pneumococcal vac-
cine acceptance occurs after nurse recommendation
varies by race/ethnicity.
Methods: We prospectively evaluated nurses' standing
orders to assess and vaccinate high-risk patients in a gener-
al medicine practice.
Results: Of 370 adult patie'nts surveyed (60% nonwhite),
78 (21%) declined vaccination following nurse recommen-
dation, and 43 (12%) persisted in declining after physician
consultation. Three-hundred-twenty-seven (88%) patients
accepted vaccination: 292 (79%) accepted following nurse
recommendation and 35 (9%) following physician consulta-
tion. African Americans (19%) were significantly more likely
to decline compared with whites (8%) and Asians (5%) (P=
0.01). Reasons for refusal included believing vaccination
was unnecessary (32%), feanng shots in general (21%), fear-
ing vaccine-induced illness (26%) and wanting more infor-
mation regarding the vaccine (9%).
Conclusion: Standing orders, physicians' firm recommenda-
tions and addressing patients' vaccine-related concerns
may reduce racial/ethnic disparties in vaccination.
Key words: Pneumococcus Uvaccination
©2006. From the Division of General Internal Medicine, Department of Medi-
cine, University of California, San Francisco, CA (Daniels, Gouveia, Null,
Gildengorin) and Centers for Disease Control and Prevention, National
Immunization Program, Atlanta, GA (Winston). Send correspondence and
reprint requests for J Natl Med Assoc. 2006;98:1089-1094 to: Dr. Nicholas A.
Daniels, University of California, San Francisco, Department of Medicine, Divi-
sion of General Internal Medicine, 1701 Divisadero St., Suite 500, Box 1731,
San Francisco, CA 94115; phone: (415) 353-7922; fax: (415) 353-7932; e-mail:
Pneumococcal vaccination reduces morbidity and
mortality and reduces healthcare costs.'`5 Standing
orders, which allow nurses and nonphysician staffto
assess and vaccinate high-risk patients without direct
involvement by physicians, have been shown to improve
adult vaccination rates.6-'0 National data from the National
Health Interview Survey (NHIS) show that racial and eth-
nic minorities aged a65 years are much less likely to
receive pneumococcal vaccination; levels ofvaccination
coverage among African Americans and Latinos were
33% and 32%, respectively, compared with 57% for
whites." These racial and ethnic disparities in vaccination
rates are not fully explained by insurance status, access to
care or health services utilization."I Other possible expla-
nations include patient preference, healthcare system fac-
tors or differences in clinical practice, and time pressures
or biases ofphysicians.
There are also a limited number ofstudies by race and
ethnicity on why people refuse pneumococcal vaccina-
tions. Some reported reasons include lack ofknowledge
and understanding of the importance of adult vaccina-
tions, reliance on the recommendation ofphysicians, and
fears that vaccines may cause illness."-'6 The objectives of
this study were to evaluate patients' acceptance and
refusal ofadult pneumococcal vaccination after nurse rec-
ommendation and to assess whether responses vary by
race and ethnicity when a vaccine is offered in a standard-
ized manner in the context ofusual care in a general inter-
nal medicine practice.
We obtained approval for this study from the institu-
tional review boards ofthe University ofCalifornia-San
Francisco (UCSF) and the U.S. Centers for Disease
Control and Prevention. In a university-based general
internal medicine clinic from June through December
2004, we evaluated standing orders for nurses to assess
patients for clinical indications and administer pneumo-
coccal vaccine ifindicated. The nurse in our study deter-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
VOL. 98, NO. 7, JULY 2006 1089
VACCINE ACCEPTANCE BY RACE/ETHNICITY
16. Centers for Disease Control and Prevention (CDC). Public health and
aging: influenza vaccination coverage among adults aged ?50 years and
pneumococcal vaccination coverage among adults aged a65 years-
United States, 2002. Morb Mortal Wkly Rep. 2003;52:987-992.
17. Whiting-O'Keefe QE, Simborg DW, Epstein WV, et al. A computerized
summary medical record system can provide more information than the
standard medical record. JAMA. 1985;254:1185-1192.
18. Whiting-O'Keefe QE, Simborg DW, Epstein WV. A controlled experiment
to evaluate the use of a time-oriented summary medical record. Med
19. Daniels NA, Nguyen TT, Gildengorin G, et al. Adult immunization in uni-
versity-based primary care and specialty practices. JAm Geriatr Soc. 2004;
20. Centers for Disease Control and Prevention (CDC). Prevention of pneu-
mococcal disease: recommendations of the Advisory Committee on
Immunization Practices (ACIP). Morb Mortal Wkly Rep. 1997;46 (No. RR-8).
21. Benisovich SV, King AC. Meaning and knowledge of health among old-
er adult immigrants from Russia: a phenomenological study. Health Educ
22. Nowalk MP, Zimmerman RK, Cleary SM, et al. Missed opportunities to vac-
cinate older adults in primary care. JAm Board Fam Pract 2005;18:20-27.
23. Szilagyi PG, Shone LP, Barth R, et al. Physician practices and attitudes
regarding adult immunizations. Prev Med. 2005;40:152-161.
24. Jacobson TA, Thomas DM, Morton FJ, et al. Use of a low-literacy patient
education tool to enhance pneumococcal vaccination rates. A random-
ized controlled trial. JAMA. 1999;282:646-650.
25. Thomas DM, Ray SM, Morton FJ, et al. Patient education strategies to
improve pneumococcal vaccination rates: randomized trial. J Investig
26. Fry AM, Zell ER, Schuchat A, et al. Comparing potential benefits of new
pneumococcal vaccines with the current polysaccharide vaccine in the
elderly. Vaccine. 2002;21:303-31 1.
27. McIntosh ED, Conway P, Willingham J, et al. Pneumococcal pneumo-
nia in the UK-how herd immunity affects the cost-effectiveness of 7-valent
pneumococcal conjugate vaccine (PCV). Vaccine. 2005;23:1739-1745.
28. Talbot TR, Poehling KA, Hartert TV, et al. Elimination of racial differences in
invasive pneumococcal disease in young children after introduction of the
conjugate pneumococcal vaccine. Pediatrlnfect Dis J. 2004;23:726-731.
29. Flannery B, Schrag S, Bennett NM, et al. Active Bacterial Core Surveil-
lance/Emerging Infections Program Network. Impact of childhood vacci-
nation on racial disparities in invasive Streptococcus pneumoniae infec-
tions. JAMA. 2004 12;291:2197-2203.
30. Whitney CG, Schaffner W, Butler JC. Rethinking recommendations for
use of pneumococcal vaccines in adults. Clin Infect Dis. 2001;33:662-675
31. U.S. Department of Health and Human Services. Healthy People 2010.
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