PURPOSE: To assess whether and how pneumococcal vaccine acceptance occurs after nurse recommendation varies by race/ethnicity. METHODS: We prospectively evaluated nurses' standing orders to assess and vaccinate high-risk patients in a general medicine practice. RESULTS: Of 370 adult patients surveyed (60% nonwhite), 78 (21%) declined vaccination following nurse recommendation, and 43 (12%) persisted in declining after physician consultation. Three-hundred-twenty-seven (88%) patients accepted vaccination: 292 (79%) accepted following nurse recommendation and 35 (9%) following physician consultation. African Americans (19%) were significantly more likely to decline compared with whites (8%) and Asians (5%) (P= 0.01). Reasons for refusal included believing vaccination was unnecessary (32%), fearing shots in general (21%), fearing vaccine-induced illness (26%) and wanting more informotion regarding the vaccine (9%). CONCLUSION: Standing orders, physicians' firm recommendations and addressing patients' vaccine-related concerns may reduce racial/ethnic disparities in vaccination.