Impact of standing orders on vaccine uptake: A systematic review.

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: Median increase of 13 percentage points across 22 standing-orders-only studies; influenza vaccine: median +12 percentage points (7 studies); pneumococcal vaccine: median +14 percentage points (5 studies)

• Primary Outcome: Vaccine uptake/coverage rate change attributable to standing orders in clinical settings

• Nnt Or Sensitivity: Not formally calculated. Contextually: a 13 percentage point absolute increase in vaccine coverage implies that for every ~8 patients managed under a standing orders protocol (compared to usual care), approximately 1 additional patient receives vaccination — though this NNT estimate is derived from the median effect size and should be interpreted cautiously given the absence of formal statistical pooling

• Confidence Interval: Not reported (narrative synthesis only; no pooled confidence intervals calculated)

Clinical Application

Standing orders are operationally feasible in most structured clinical environments. Implementation requires: (1) institutional policy development and legal authorisation for non-physician vaccine administration; (2) staff training for nurses, pharmacists, or other authorised providers; (3) integration with electronic health records or paper-based screening tools to identify eligible patients; (4) governance structures for adverse event management. Multi-component approaches pairing standing orders with provider-directed and patient-directed interventions appear common in practice and may enhance uptake further. Standing orders for vaccination are supported within the Australian immunisation framework. The Australian Immunisation Handbook (published by the Australian Government Department of Health and Aged Care) provides guidance on authorised vaccine administration by nurses and pharmacists under standing orders or similar protocols. The Therapeutic Goods Administration (TGA) regulates vaccine products, while the Pharmaceutical Benefits Scheme (PBS) and National Immunisation Program (NIP) fund key vaccines including seasonal influenza and pneumococcal vaccines for eligible populations. RACGP Standards for general practice support nurse-administered vaccines under standing orders in primary care. Aged care facilities and Aboriginal and Torres Strait Islander health services represent high-priority settings where standing orders could meaningfully address documented vaccination gaps. State and territory variation in authorisation frameworks for pharmacist-administered vaccines under standing orders remains a practical consideration for implementation. Adult patients in clinical settings where vaccination is indicated, particularly for seasonal influenza and pneumococcal disease. Most applicable to inpatient wards, aged care facilities, outpatient clinics, and community pharmacy settings. Evidence for paediatric populations and childhood vaccination schedules is limited and identified as a research gap by the authors.

Abstract

OBJECTIVE: We sought to evaluate the impact of standing orders on vaccine coverage in clinical settings. METHODS: Two reviewers independently screened and included studies that evaluated use of standing orders either alone or in combination with other interventions and collected data on vaccine coverage. We extracted effect sizes for studies that used only standing orders as an intervention and had a comparison group. RESULTS: The search yielded 56 eligible studies, 22 of which evaluated standing orders-only interventions. Standing orders increased vaccine uptake by a median of 13 percentage points (IQR 2-20 percentage points). Eight of these studies had a comparison group including 1 randomized trial; 5 were at low risk of bias. The overall findings were similar those for seasonal influenza vaccine (median increase of 12 percentage points; IQR, 6-24; 7 studies) and pneumococcal vaccines (14 percentage points; 2-20; 5 studies), the two most studied outcomes. Multi-component studies paired standing orders with interventions for providers frequently (34%-63% of studies), patients often (20%-49%), and systems least often (3%-14%). CONCLUSIONS: Standing orders show one of the largest effects among vaccine uptake interventions. Future research should focus on randomized trials, childhood vaccination, and behavioral aspects of implementation in healthcare systems.

References

1. 1.Ellingson, M. K., Sudarsanam, V., Goddard, K., Tomar, A., Nachman, S., & Brewer, N. T. (2026). Impact of standing orders on vaccine uptake: A systematic review. Vaccine. https://doi.org/10.1016/j.vaccine.2026.128664