- Standing orders authorize non-physician health professionals (NPHP) to provide patient care following protocols often based on national clinical guidelines, including administering federally recommended vaccines without a physician’s pre-screening examination prior to vaccination.
- Civilians and military personnel are subject to vaccination standing orders in settings such as hospitals and in-patient/outpatient medical facilities, pharmacies, workplaces, etc.
- Standing orders raise safety issues and may restrict the right to exercise informed consent.
In the year 2000, the Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control and Prevention (CDC) published recommendations based on the effectiveness of vaccination “standing order” programs, which are put in place in settings providing health care, including medical facilities, pharmacies and even the workplace, increase vaccination rates among adults and children.1
What is a “Standing Order”?
Standing orders allow non-physician health professionals to treat patients following protocols that are often based on national clinical guidelines.2
According to the CDC’s 2000 report, vaccination standing order protocols authorize nurses and pharmacists to administer vaccinations according to an institution- or physician-approved protocol without a physician’s exam.” The report states that vaccination standing order programs can be implemented in multiple settings that include inpatient and outpatient facilities, long-term-care facilities, managed-care organizations, assisted living facilities, correctional facilities, pharmacies, adult workplaces, home health-care agencies, client, resident and employee settings.1
The Immunization Action Coalition (IAC) is a national non-profit organization funded by the CDC and vaccine manufacturers Astra Zeneca, GlaxoSmithKline, Merck, Pfizer, Sanofi Pasteur and Seqiris.3 4 IAC “works to increase immunization rates” and lobbies for vaccine mandates and the elimination of vaccine exemptions.5 In recent years, IAC has added, “other appropriately trained healthcare personnel where allowed by state law” to the list of those who can administer vaccines under standing orders.6
As with all vaccination protocols, the U.S. Department of Defense (DoD) follows the recommendations published by the CDC’s ACIP as the basis for issuing vaccination standing orders that apply to active duty military personnel and family dependents, as well.7 Currently, the ACIP has 44 vaccines listed as part of the DoD standing orders program, out of which five vaccines were added to the list beginning January 2019. The vaccines that have been recently added include HPV (Gardasil 9); Inactivated Polio Vaccine for adults; varicella zoster (Varivax) chickenpox vaccine for adults; Japanese encephalitis (Ixiaro) vaccine for adults and Japanese encephalitis (Ixiaro) children and adolescents.6
The DoD Military Health System’s website states that a physician must still be available to respond to a medical emergency when vaccines are administered should the patient suffer an immediate adverse effect that could be life threatening; however, the DoD website also states, “The use of standing orders in the military allows healthcare personnel working within their scope of practice as determined by their license and each Service to administer vaccines without an individual order or physician’s exam. This saves both the individual vaccinee and the provider time, while allowing for a safe and efficient vaccine delivery process in the absence of adequate allergy and immunology specialists.”6
The list of vaccines that can be giving under standing orders to all children and adults in the U.S. is listed here on the IAC website.
Safety Implications of Standing Orders
One of the major safety concerns relating to vaccination standing orders is that it eliminates the need for a physician’s pre-screening examination. Although non-physician health professionals (NPHP) are required to assess and screen patients for potential vaccine contraindications and precautions before administering a vaccine,1 this is unlikely to occur given that there are almost no medical contraindications to vaccination today8 and health care professionals are taught that vaccines are generally safe for everyone, even though it is clear that there are known and unknown biological risk factors that make some individuals more susceptible to being harmed by vaccinations.9
This creates a potentially dangerous situation for children and adults getting their vaccines under standing orders protocols and leads to another question: Are non-physician NPHPs monitoring and reporting serious vaccine reactions, hospitalizations, injuries and deaths that follow the vaccinations they administer to people to the federal Vaccine Adverse Events Reporting System (VAERS)? Since NPHPs are now administering a substantial portion of vaccines given to children and adults in the U.S., are they obeying the legal responsibility of reporting vaccine adverse events to VAERS mandated under the National Childhood Vaccine Injury Act of 1986 or are they simply ignoring vaccine reactions and failing to report?10
The human right to exercise informed consent to medical risk taking is also violated under standing orders that allow health professionals to coerce individuals to receive vaccines without their informed and voluntary consent. Regardless of what a health professional’s beliefs are about the benefits and risks of vaccination, informed consent is required for all medical interventions that carry a risk of harm, such as surgery or the use of pharmaceutical products that carry the risk of injury or death.11
The informed consent principle stems from the human right to autonomy.12 Patients have the legal right to be fully informed about the benefits, risks and failures of a physician-recommended medical procedure prior to making an informed and voluntary decision about whether or not to accept the risks.13
The right to autonomy, which includes the right to exercise freedom of thought, conscience and religion, is an internationally recognized human right.14 Standing orders that enable a physician or NPHP to coerce people against their conscience into agreeing to a medical intervention, such as vaccination, is a violation of a basic human right.
1 Centers for Disease Control and Prevention. Use of Standing Orders Programs to Increase Adult Vaccination Rates. Morbidity and Mortality Weekly Report 2000; 49(RR01): 15-26.
2 Center for Excellence in Primary Care. University of California-San Francisco 2013.
3 Immunization Action Coalition. IAC Funding 2018. Nov. 15, 2018.
4 Immunization Action Coalition. Advisory Board. Mar. 7, 2018
5 NVIC Advocacy Portal Team. State Vaccine Legislation in American 2015-2017: Follow the Money. National Vaccine Information Center Oct. 25, 2017.
6 Immunization Action Coalition. Using Standing Orders for Administering Vaccines: What You Should Know. Immunization Action Coalition December 2018.
7 The Military Health System. Standing Orders. Health.mil January 2019.
8 CDC. Vaccine Recommendations and Guidelines of the ACIP: Jan. 10, 2019. CDC.gov.
9 Health Resources & Services Administration. Vaccine Injury Compensation Program Data and Statistics. HRSA.gov Mar. 1, 2017.
10 Parpia R. The Safety Implications of Pharmacists Giving Vaccines. The Vaccine Reaction Apr. 22, 2017.
11 Parpia R. Biologics R Vaccines: Beware of “Informed Consent”. The Vaccine Reaction Jan. 31, 2018.
12 Dryden J. Autonomy. Internet Encyclopedia of Philosophy
13 Fisher BL. Why Is Informed Consent a Human Right? NVIC Newsletter June 28, 2017.
14 Universal Declaration of Human Rights. United Nations Dec. 10, 1948.