‘Standing Orders’ for Immunizations

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends the implementation of “standing orders” to ensure that influenza and pneumococcal immunizations are administered routinely to elderly and high-risk patients who are entering the hospital, a nursing home or other health care facility.

Influenza epidemics occur nearly every winter in the United States, causing an average of 20,000 deaths per year. Pneumococcal disease, which is a group of diseases caused by the pneumococcus bacteria, is responsible for 3,000 cases of meningitis, 50,000 cases of bacteremia and 500,000 cases of pneumonia every year in the United States, according to ACIP. It is also responsible for more deaths than any other bacterial disease preventable by vaccination.

Influenza and pneumococcal disease strike hardest among persons 65 years of age and older and those younger than 65 who have medical conditions that put them at high risk for complications. ACIP notes that standing orders for immunizations against influenza and pneumococcal disease would allow nonphysician health care personnel to administer the vaccines in high-risk patients without first requiring examination by a physician.

ACIP also encourages the implementation of standing orders programs for vaccination of adults in outpatient settings, managed care organizations, assisted living facilities, correctional facilities, home health care agencies and long-term care facilities, such as nursing homes and skilled nursing facilities.

Information about influenza and pneumococcal vaccines and vaccine-preventable diseases may be obtained by calling the CDC National Immunization Information Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).

Fetal Screening in the First Trimester

The Committee on Genetics of the American College of Obstetricians and Gynecologists (ACOG) has published an opinion paper on first-trimester screening for fetal anomalies with nuchal translucency (ACOG Committee Opinion No. 223). The paper appears in the October 1999 issue of Obstetrics and Gynecology.

Maternal serum screening during the second trimester of pregnancy is the current method of screening women who are at low risk for carrying fetuses with neural tube defects, chromosome abnormalities and other fetal malformations. However, the ACOG committee feels that screening in the first trimester for fetal chromosome abnormalities may offer many advantages over screening in the second trimester. First-trimester screening helps to relieve maternal anxiety earlier in the pregnancy and allows the patient to use chorionic villus sampling. If the fetus is found to be affected, the patient may elect to terminate the pregnancy, which, in the first trimester, is associated with reduced maternal morbidity.

Finding nuchal translucency on ultrasonography in the first trimester has been associated with fetal abnormalities, according to the committee. However, much of the early data on nuchal translucency screening involved high-risk women being tested for indications such as advanced maternal age or family history of chromosome abnormality. Studies of low-risk women have produced conflicting results, attributable to variation in nuchal translucency measurements. There is no consensus on the definition of increased nuchal translucency. In most of the reports, the measurements were taken from the sagittal section of the fetus that is usually used to obtain the crown-rump length. Some researchers, however, used a transverse suboccipitobregmatic view of the fetal head to obtain the measurement.

The ACOG committee feels that first-trimester screening for fetal abnormalities using the nuchal translucency marker alone or in combination with serum markers appears promising but should remain under investigation. According to the committee, the technique for measuring nuchal translucency and the criteria for defining increased nuchal translucency must be standardized. Until further studies confirm the efficacy of first-trimester screening, with or without serum markers, the ACOG committee does not recommend this method for routine clinical use.

Routine Screening for Domestic Violence

The Family Violence Prevention Fund, in collaboration with health care and domestic violence experts, has developed new policy guidelines that urge health care professionals to routinely screen patients for domestic abuse.

Most experts feel that properly trained physicians and other health care professionals are in a unique position to help battered women. However, one study published in the August 4, 1999 issue of JAMA found that less than 10 percent of primary care physicians routinely screen their patients for domestic abuse during regular office visits. The new screening guidelines are designed to help health care professionals screen patients effectively. The guidelines include recommendations on which patients should be screened and when screening should occur, suggested screening questions, a documentation form and a reference card that outlines the steps physicians can take to help battered patients.

“This work is incredibly important,” said Esta Soler, executive director of the Family Violence Prevention Fund. “Many victims of domestic violence are not comfortable seeking help from friends or going to shelters. Yet, they visit their health care providers for routine and emergency care. The health setting is often the safest place for these women to seek help—if doctors and nurses know how to detect abuse, and offer referrals and support. When health care providers take time to ask patients a few simple questions about domestic violence, they save lives.”

The National Health Resource Center on Domestic Violence, which is operated by the Family Violence Prevention Fund, is distributing the new screening guidelines free of charge. Packets containing the guidelines can be obtained by calling 888-RX-ABUSE. The packet also includes tips for intervention in and assessment of domestic violence, tips for organizing a hospital or clinic to screen patients for abuse, and background information.