A vaccination standing order is a document that authorizes appropriately trained healthcare personnel to assess a patient’s immunization status and administer vaccinations according to a protocol approved by an authorized practitioner, when allowed by state law. In our busy healthcare settings, standing orders are often useful because they bypass what may be the rate-limiting step in immunizing children: the need for clinician examination or direct order from the attending provider at the time of the interaction. Healthcare professionals can also use standing orders to review contraindications and verify that each vaccine is administered using the correct indications, precautions and route of administration. In short, standing orders templates can help guide clinicians through complicated vaccination recommendations.
In this issue of Technically Speaking, we focus on the use of published standing orders to assess a patient's need for a vaccine and to administer it without a physician's direct order. Immunize.org offers up-to-date standing order templates for vaccines routinely administered to children and adults. See the list on the "Clinical Resources: Standing Orders Templates" webpage. Use the “Sort by: Updated Date Newest” filter to view the most recent updates. Each template title indicates the vaccine it is for and when it was most recently updated.
Many standing orders templates have recently been updated, including those for vaccination against COVID-19, respiratory syncytial virus (RSV), influenza (flu), meningococcal disease caused by serotypes A, C, W and Y (MenACWY), and pneumococcus. To demonstrate the types of information you can find on standing order templates, we pose a series of questions and answers below. Check them out:
QUESTION 1
In July 2024, Immunize.org updated RSV standing orders templates for both maternal vaccination (Abrysvo, Pfizer) and infant immunization with the long-acting RSV monoclonal antibody, nirsevimab (Beyfortus, Sanofi).
Based on these updated templates, which of the following is/are true?
- There is a shortage of nirsevimab, so it’s best to attempt to vaccinate the mother during pregnancy.
- There is a shortage of nirsevimab, so it’s best to attempt to vaccinate both parents during the pregnancy.
- If maternal vaccination was not received at least two weeks prior to delivery and nirsevimab is unavailable, palivizumab (Synagis) should be administered to eligible high-risk infants according to AAP recommendations for palivizumab.
- The Pfizer RSV vaccine (Abrysvo) may be given to a pregnant individual who has experienced a serious reaction (e.g., anaphylaxis) to one of its components.
ANSWER: Option C is true. Providers caring for high-risk infants who require protection from RSV should be aware of all options.
Answers A, B and D are all false. Nirsevimab is not expected to be in short supply this season, so either infant immunization or maternal vaccination is appropriate. Recall that maternal vaccination protects the infant through passive transfer of antibodies, so RSV vaccination of non-pregnant partners is not recommended. No vaccine should be administered to someone who experienced a serious reaction (e.g., anaphylaxis) to one of its components.
QUESTION 2
Based on the template titled, “Standing Orders for Administering Influenza Vaccine to Children and Teens,” which of the following is/are true?
- The Advisory Committee on Immunization Practices (ACIP) states that solid organ transplant recipients aged 18 through 64 years who are receiving immunosuppressive medication regimens may receive either high-dose (HD-IIV3) or adjuvanted (aIIV3) influenza vaccine as acceptable options without a preference over other age-appropriate injectable influenza vaccines.
- If an 8-year-old child receives their first lifetime dose of flu in the beginning of the 2024-25 flu season and then turns 9 prior to receiving their second dose, a second dose of flu vaccine is still needed this season.
- There should be at least one week between injectable influenza vaccination and receipt of other vaccines (e.g., COVID-19 vaccine).
- Severe egg allergy is a contraindication to administration of any influenza vaccine (egg-based or non-egg-based).
ANSWER: A and B are true and are reviewed in the first section of the procedure detailing how to assess children and adolescents’ need for vaccination. Option C is false. IIV3s and RIV3 (i.e., injectable influenza vaccines) may be administered simultaneously or sequentially with other vaccines, regardless of if those are live or inactivated. Option D is false, too. Any influenza vaccine that is otherwise appropriate for the recipient’s age and health status (egg based or non-egg based) can be administered to persons with egg allergy. For more on each of these, see "Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2024-25 Influenza Season."
QUESTION 3
"Standing Orders for Administering Pneumococcal Vaccines to Children and Teens" are much more complex than most routine vaccination standing orders and deserve careful review.
Based on this template, which of the following is/are true?
- Pneumococcal vaccination recommendations are the same for children with immunocompromising conditions (e.g., sickle cell disease) and non-immunocompromising conditions (e.g., moderate persistent asthma).
- A 4-year-old with moderate persistent asthma completed the PCV series with PCV15 but never had a dose of PCV20 or PPSV23 (pneumococcal polysaccharide vaccine). One acceptable option is for this patient to receive one dose of PCV20 at least eight weeks after the most recent PCV dose.
- An 18-month-old healthy infant who received two doses of PCV previously needs one additional dose at least eight weeks after the most recent dose.
- An 18-month-old infant with diabetes mellitus who received two doses of PCV previously needs one additional dose at least eight weeks after the most recent dose.
ANSWER: B, C and D are true. Review Table 4, the row for children “2 through 18 years (non-IC only)”. Options C and D are also reflected in Table 1.
Option A is false. Risk-based pneumococcal vaccination recommendations are divided by type of risk condition. For example, look at Table 4 of the “Standing Orders for Administering Pneumococcal Vaccines to Children and Teens” document. Compare the rows of children 2 through 18 years of age who completed the PCV series before 6 years of age with PCV13 and/or PCV15 but did not receive a previous dose of PCV20 or PPSV23. If the option to use PPSV23 is used, the follow-up is different depending on whether the child has an immunocompromising or non-immunocompromising condition.
Note that Immunize.org also updated “Standing Orders for Administering Pneumococcal Vaccines to Adults” in July 2024 to reflect that the Centers for Disease Control and Prevention (CDC) now include 21-valent pneumococcal conjugate vaccine (PCV21) as an acceptable option for adults recommended to receive PCV. Note that, unlike PCV15 and PCV20 which are routinely recommended for children, PCV21 does not provide protection against certain serotypes historically responsible for a significant burden of disease in children. Thus, PCV21 is not licensed or recommended for use in children.
Editor’s note: The standing orders template for adults getting pneumococcal vaccine will likely be updated again soon to reflect the ACIP’s October 2024 recommendation to lower the age of eligibility for routine vaccination from 65 years to 50 years.
QUESTION 4
Based on the template titled, “Standing Orders for Administering Meningococcal ACWY Vaccine to Children and Teens,” which of the following is/are true?
- Menactra (Sanofi) may be used for children as young as 2 months of age.
- Use of Enjaymo (sutimlimab), a new, FDA‑approved complement-inhibiting treatment for people with cold agglutinin disease, is an indication for meningococcal vaccination.
- Regarding Menveo preparations, the lyophilized package may be used beginning at 2 months of age; the liquid package may be used beginning at 10 years of age.
- Routine MenACWY vaccination is only indicated for first-year college students living in a residential facility who were never vaccinated before.
ANSWER: B and C are true. Option A suggests the use of Menactra (Sanofi), but this product is no longer available in the United States. Option D is false, too. In fact, routine MenACWY vaccination is indicated for first-year college students living in a residential facility under three conditions: They were never vaccinated; they were last vaccinated when younger than 16 years of age; or their most recent dose — if given at 16 years of age or older — was administered more than five years earlier.
Standing order updates
Although staying abreast of frequently updated standing order templates can be time consuming, they remain invaluable, as updates to electronic health records often lag. The standing orders templates highlighted in this article are maintained with painstaking attention to detail so that all providers can benefit. To find these, use Immunize.org’s "Clinical Resources" main page. Choose “Standing Orders Templates” from the right side of the page and then filter the choices until you see what you need.
Contributed by: Sharon G. Humiston, MD, MPH, FAAP
A vaccination standing order is a document that authorizes appropriately trained healthcare personnel to assess a patient’s immunization status and administer vaccinations according to a protocol approved by an authorized practitioner, when allowed by state law. In our busy healthcare settings, standing orders are often useful because they bypass what may be the rate-limiting step in immunizing children: the need for clinician examination or direct order from the attending provider at the time of the interaction. Healthcare professionals can also use standing orders to review contraindications and verify that each vaccine is administered using the correct indications, precautions and route of administration. In short, standing orders templates can help guide clinicians through complicated vaccination recommendations.
In this issue of Technically Speaking, we focus on the use of published standing orders to assess a patient's need for a vaccine and to administer it without a physician's direct order. Immunize.org offers up-to-date standing order templates for vaccines routinely administered to children and adults. See the list on the "Clinical Resources: Standing Orders Templates" webpage. Use the “Sort by: Updated Date Newest” filter to view the most recent updates. Each template title indicates the vaccine it is for and when it was most recently updated.
Many standing orders templates have recently been updated, including those for vaccination against COVID-19, respiratory syncytial virus (RSV), influenza (flu), meningococcal disease caused by serotypes A, C, W and Y (MenACWY), and pneumococcus. To demonstrate the types of information you can find on standing order templates, we pose a series of questions and answers below. Check them out:
QUESTION 1
In July 2024, Immunize.org updated RSV standing orders templates for both maternal vaccination (Abrysvo, Pfizer) and infant immunization with the long-acting RSV monoclonal antibody, nirsevimab (Beyfortus, Sanofi).
Based on these updated templates, which of the following is/are true?
- There is a shortage of nirsevimab, so it’s best to attempt to vaccinate the mother during pregnancy.
- There is a shortage of nirsevimab, so it’s best to attempt to vaccinate both parents during the pregnancy.
- If maternal vaccination was not received at least two weeks prior to delivery and nirsevimab is unavailable, palivizumab (Synagis) should be administered to eligible high-risk infants according to AAP recommendations for palivizumab.
- The Pfizer RSV vaccine (Abrysvo) may be given to a pregnant individual who has experienced a serious reaction (e.g., anaphylaxis) to one of its components.
ANSWER: Option C is true. Providers caring for high-risk infants who require protection from RSV should be aware of all options.
Answers A, B and D are all false. Nirsevimab is not expected to be in short supply this season, so either infant immunization or maternal vaccination is appropriate. Recall that maternal vaccination protects the infant through passive transfer of antibodies, so RSV vaccination of non-pregnant partners is not recommended. No vaccine should be administered to someone who experienced a serious reaction (e.g., anaphylaxis) to one of its components.
QUESTION 2
Based on the template titled, “Standing Orders for Administering Influenza Vaccine to Children and Teens,” which of the following is/are true?
- The Advisory Committee on Immunization Practices (ACIP) states that solid organ transplant recipients aged 18 through 64 years who are receiving immunosuppressive medication regimens may receive either high-dose (HD-IIV3) or adjuvanted (aIIV3) influenza vaccine as acceptable options without a preference over other age-appropriate injectable influenza vaccines.
- If an 8-year-old child receives their first lifetime dose of flu in the beginning of the 2024-25 flu season and then turns 9 prior to receiving their second dose, a second dose of flu vaccine is still needed this season.
- There should be at least one week between injectable influenza vaccination and receipt of other vaccines (e.g., COVID-19 vaccine).
- Severe egg allergy is a contraindication to administration of any influenza vaccine (egg-based or non-egg-based).
ANSWER: A and B are true and are reviewed in the first section of the procedure detailing how to assess children and adolescents’ need for vaccination. Option C is false. IIV3s and RIV3 (i.e., injectable influenza vaccines) may be administered simultaneously or sequentially with other vaccines, regardless of if those are live or inactivated. Option D is false, too. Any influenza vaccine that is otherwise appropriate for the recipient’s age and health status (egg based or non-egg based) can be administered to persons with egg allergy. For more on each of these, see "Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2024-25 Influenza Season."
QUESTION 3
"Standing Orders for Administering Pneumococcal Vaccines to Children and Teens" are much more complex than most routine vaccination standing orders and deserve careful review.
Based on this template, which of the following is/are true?
- Pneumococcal vaccination recommendations are the same for children with immunocompromising conditions (e.g., sickle cell disease) and non-immunocompromising conditions (e.g., moderate persistent asthma).
- A 4-year-old with moderate persistent asthma completed the PCV series with PCV15 but never had a dose of PCV20 or PPSV23 (pneumococcal polysaccharide vaccine). One acceptable option is for this patient to receive one dose of PCV20 at least eight weeks after the most recent PCV dose.
- An 18-month-old healthy infant who received two doses of PCV previously needs one additional dose at least eight weeks after the most recent dose.
- An 18-month-old infant with diabetes mellitus who received two doses of PCV previously needs one additional dose at least eight weeks after the most recent dose.
ANSWER: B, C and D are true. Review Table 4, the row for children “2 through 18 years (non-IC only)”. Options C and D are also reflected in Table 1.
Option A is false. Risk-based pneumococcal vaccination recommendations are divided by type of risk condition. For example, look at Table 4 of the “Standing Orders for Administering Pneumococcal Vaccines to Children and Teens” document. Compare the rows of children 2 through 18 years of age who completed the PCV series before 6 years of age with PCV13 and/or PCV15 but did not receive a previous dose of PCV20 or PPSV23. If the option to use PPSV23 is used, the follow-up is different depending on whether the child has an immunocompromising or non-immunocompromising condition.
Note that Immunize.org also updated “Standing Orders for Administering Pneumococcal Vaccines to Adults” in July 2024 to reflect that the Centers for Disease Control and Prevention (CDC) now include 21-valent pneumococcal conjugate vaccine (PCV21) as an acceptable option for adults recommended to receive PCV. Note that, unlike PCV15 and PCV20 which are routinely recommended for children, PCV21 does not provide protection against certain serotypes historically responsible for a significant burden of disease in children. Thus, PCV21 is not licensed or recommended for use in children.
Editor’s note: The standing orders template for adults getting pneumococcal vaccine will likely be updated again soon to reflect the ACIP’s October 2024 recommendation to lower the age of eligibility for routine vaccination from 65 years to 50 years.
QUESTION 4
Based on the template titled, “Standing Orders for Administering Meningococcal ACWY Vaccine to Children and Teens,” which of the following is/are true?
- Menactra (Sanofi) may be used for children as young as 2 months of age.
- Use of Enjaymo (sutimlimab), a new, FDA‑approved complement-inhibiting treatment for people with cold agglutinin disease, is an indication for meningococcal vaccination.
- Regarding Menveo preparations, the lyophilized package may be used beginning at 2 months of age; the liquid package may be used beginning at 10 years of age.
- Routine MenACWY vaccination is only indicated for first-year college students living in a residential facility who were never vaccinated before.
ANSWER: B and C are true. Option A suggests the use of Menactra (Sanofi), but this product is no longer available in the United States. Option D is false, too. In fact, routine MenACWY vaccination is indicated for first-year college students living in a residential facility under three conditions: They were never vaccinated; they were last vaccinated when younger than 16 years of age; or their most recent dose — if given at 16 years of age or older — was administered more than five years earlier.
Standing order updates
Although staying abreast of frequently updated standing order templates can be time consuming, they remain invaluable, as updates to electronic health records often lag. The standing orders templates highlighted in this article are maintained with painstaking attention to detail so that all providers can benefit. To find these, use Immunize.org’s "Clinical Resources" main page. Choose “Standing Orders Templates” from the right side of the page and then filter the choices until you see what you need.
Contributed by: Sharon G. Humiston, MD, MPH, FAAP