Pneumococcal Vaccination Laws for Ambulatory Care Facilities

What to know

Ambulatory care facilities can have requirements for vaccines for patients and healthcare workers that vary across the country. Find information about the only state—Texas—with a requirement for pneumococcal vaccines for patients. CDC recommends that adults aged 50 years or older receive the pneumococcal vaccine.

Purpose

This menu is one of a series of menus assessing vaccination requirements for patients and healthcare workers in healthcare facilities. To reduce the risk of disease transmission and outbreaks, healthcare facilities across the country are increasingly requiring healthcare workers to be vaccinated for certain vaccine-preventable diseases.1 In some instances, facilities are establishing these requirements under mandates set forth by state statutes or regulations. Depending on the vaccine, the legal requirements might apply to patients, healthcare workers, or both and can include the following types of provisions:

  • Assessment requirements: The healthcare facility must assess a healthcare worker or patient's vaccination status.2
  • Administrative requirements for offering vaccination: The healthcare facility must offer a vaccination to a healthcare worker or patient.3
  • Administrative requirements for ensuring vaccination: The healthcare facility must require a healthcare worker or patient to demonstrate proof of vaccination or immunity against a specific vaccine preventable disease.4

Streptococcus pneumoniae bacteria, or pneumococcus, can cause many types of illnesses; some of these illnesses can be life-threatening.5 In fact, pneumococcus is one of the most common causes of severe pneumonia.6 Each year in the United States, invasive pneumococcal disease causes thousands of infections, such as meningitis, bloodstream infections, and pneumonia.7 Pneumococcal vaccines are very good at preventing severe disease, hospitalization, and death.8

In healthcare settings, pneumococcal bacteria can spread between healthcare workers and patients through direct contact with respiratory secretions.9 Despite the risks associated with pneumococcal bacterial infection, no state establishes pneumococcal vaccination requirements for healthcare workers in ambulatory care facilities, and currently only one state―Texas—has requirements for patients in these facilities.10

This menu assesses Texas's laws, which expressly establish pneumococcal vaccination requirements for patients at renal dialysis facilities, a type of ambulatory care facility.11 Research for this menu did not reveal additional states with laws related to ambulatory care facilities in general or to specific types of ambulatory care facilities, such as birth centers or surgical centers.

CDC recommends that adults aged 65 years or older receive the pneumococcal vaccine. Visit CDC's Recommended Vaccines for Adults web page for information about this and other recommended vaccines. To learn more, visit CDC's Pneumococcal Vaccination page.

Texas pneumococcal vaccination laws for ambulatory care facility patients

Ambulatory care facilities are healthcare facilities that provide outpatient medical services. Examples of ambulatory care facilities include birth centers, dialysis facilities, and surgical centers. Texas is the only state with a law that establishes pneumococcal vaccination requirements for ambulatory care patients, specifically patients in dialysis facilities for end-stage renal disease.

Facility type: dialysis facility for end-stage renal disease (ESRD)

  • ESRD facilities provide dialysis treatment or training to individuals with end-stage renal disease.12 Texas law "require[s] an end stage renal disease facility to offer, to the extent possible as determined by the facility, the opportunity to receive the pneumococcal" vaccination.13

"

Individual type: patients 50 and older

  • The person administering a vaccine in an ESRD facility must "ask whether the elderly person is currently vaccinated against . . . pneumococcal disease."14 Texas law defines "elderly person" as "a person who is 65 years of age or older."15

Requirement type: assessment requirements and offer requirements

  • The person administering the vaccine must also "ask whether the elderly person is currently vaccinated against the influenza virus or pneumococcal disease, as appropriate."16
  • Texas law "require[s] an end stage renal disease facility to offer, to the extent possible as determined by the facility, the opportunity to receive the pneumococcal" vaccine.17

Exemption type: medical

  • Once an elderly patient has elected to receive the pneumococcal vaccination, the person administering the vaccine must make an assessment for medical contraindications before he or she "administer[s] the vaccine under institution-approved or physician-approved protocols . . ."18 Note that even where not explicitly exempted by law, it is likely that patients with a medically contraindicated condition are not required to be vaccinated.

Acknowledgements and disclaimers

This document was developed by Alexandra Bhatti, JD, MPH, contractor, Cherokee Nation Assurance, LLC; Adebola Popoola, MS, MPH, JD candidate 2017, Atlanta's John Marshall Law School, and Fall 2016 Public Health Law Program (PHLP) extern; Aila Hoss, JD, former contractor, Carter Consulting, Inc.; and Dawn Pepin, JD, MPH, contractor, Cherokee Nation Assurance, LLC, with PHLP within the Centers for Disease Control and Prevention's (CDC's) National Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce. This document was produced in collaboration with CDC's National Center for Immunization and Respiratory Diseases. The authors thank Lindsay Culp, JD, MPH; Megan Lindley, MPH; and Matthew Penn, JD, MLIS, for their research and editorial assistance.

For further technical assistance with this inventory, please contact phlawprogram@cdc.gov. PHLP provides technical assistance and public health law resources to advance the use of law as a public health tool. PHLP cannot provide legal advice on any issue and cannot represent any individual or entity in any matter. PHLP recommends seeking the advice of an attorney or other qualified professional with questions regarding the application of law to a specific circumstance. The findings and conclusions in this summary are those of the authors and do not necessarily represent the official views of CDC.

This menu includes states' laws collected from WestlawNext during October 19–27, 2016.

Facility type—pneumococcal vaccination laws for ambulatory care facilities

State Citation Ambulatory Care Facility Type
All AC facilities ESRD Facility
Ambulatory Care Facility Type
TX V.T.C.A., Health & Safety Code § 161.0052, Tex. Health & Safety Code Ann. § 251.001* X
25 TAC § 117.33, 25 TAC § 117.2* X

Patient type—pneumococcal vaccination laws for ambulatory care facilities

State Citation Patient Type
All patients 65+ years of age Patients at risk
Patient Type
TX V.T.C.A., Health & Safety Code § 161.0052, Tex. Health & Safety Code Ann. § 251.001* X
25 TAC § 117.33, 25 TAC § 117.2* X

Requirement type—pneumococcal vaccination laws for ambulatory care facilities

State Citation Requirement Type
Assessment Administrative offer Administrative ensure
Requirement Type
TX V.T.C.A., Health & Safety Code § 161.0052, Tex. Health & Safety Code Ann. § 251.001* X X
25 TAC § 117.33, 25 TAC § 117.2* X X

Exemptions—pneumococcal vaccination laws for ambulatory care facilities

State Citation Exemptions
None specified Medical Religious Philosophical19
Exemptions
TX V.T.C.A., Health & Safety Code § 161.0052, Tex. Health & Safety Code Ann. § 251.001* X
25 TAC § 117.33, 25 TAC § 117.2* X

See a combined PDF of these tables.

See a PDF of the menu.

Published April 2017 & updated October 2017

Author's note:
Updates include the change of Ensure Requirement definition from "requiring a healthcare facility to ensure that a healthcare worker or patient has been vaccinated, unless vaccination is specifically exempted or declined" to "the healthcare facility must require a healthcare worker or patient to demonstrate proof of vaccination or immunity against a specific vaccine preventable disease". This change did not alter the coding results.

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Content Source:
Public Health Infrastructure Center; Public Health Law
  1. Alexandra Stewart et al. Mandatory Vaccination of Health-Care Personnel: Good Policy, Law, and Outcomes, 53 Jurimetrics J. 341 (Apr. 2013).
  2. Meagan Lindley, Gail Horlick, Abigail Shefer, Fredric Shaw & Margaret Gorji. Assessing State Immunization Requirements for Healthcare Workers and Patients. Am. j. of preventive med. 32(6), 459–65, 460 (2007).
  3. Id.
  4. Id.
  5. Types of Infection, Centers for Disease Control and Prevention, (last visited Jan. 17, 2017).
  6. Types of Infection, Centers for Disease Control and Prevention, (last visited Jan. 17, 2017).
  7. Pneumococcal Vaccination, Centers for Disease Control and Prevention, (last visited Jan. 17, 2017).
  8. Pneumococcal Vaccination, Centers for Disease Control and Prevention, (last visited Jan. 17, 2017).
  9. About Pneumococcal Disease, Centers for Disease Control and Prevention, (last visited Jan. 12, 2017).
  10. Texas. See appendix for citations.
  11. CDC’s Public Health Law Program conducted a search for state statutes and regulations that establish pneumococcal vaccination requirements for ambulatory care healthcare workers and patients using WestlawNext, a legal research database. Searches were conducted in all states and the District of Columbia on October 19, 2016. This assessment did not capture state requirements that incorporate CDC vaccination recommendations by reference. Laws not within the scope of this assessment included those regarding childhood vaccinations; school vaccinations; immunization registries; blood, tissue, and organ donor requirements; post-exposure vaccinations; physician standing orders; and primary care providers and individual healthcare provider requirements to vaccinate patients. Laws establishing vaccination requirements as a condition for participation in a health plan were also excluded.
  12. Tex. Health & Safety Code Ann. § 251.001(6).
  13. See Tex. Health & Safety Code Ann. § 161.0052; 25 Tex. Admin. Code § 117.33.
  14. Tex. Health & Safety Code Ann. § 161.0052(e).
  15. Tex. Health & Safety Code Ann. § 161.0052(a).
  16. Tex. Health & Safety Code Ann. § 161.0052(e).
  17. Tex. Health & Safety Code Ann. § 161.0052(c).
  18. Id.
  • Philosophical exemptions include exemptions based on philosophical or personal beliefs or those allowing the right to decline an immunization.