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Background: Influenza and pneumococcal disease are major causes of vaccine-preventable death among the elderly. In an effort to raise immunization rates, New Jersey in 1999 adopted a regulation requiring hospitals to offer pneumococcal and influenza vaccinations to all inpatients aged 65 and over. This study examined the effect of implementation strategies on immunization rates within hospitals in 2000 and 2001., Methods: Hospital infection control directors were surveyed and random chart review was conducted from a stratified sample of hospitals. The infection control director's assessment of their institution's success was a major outcome measure., Results: Relatively few respondents thought their hospital has been successful in implementing new immunization protocols. Approximately 67% responded that they did not think physicians agreed with the "scope and nature" of the regulation. Physician attitudes led the list of barriers to implementation cited by respondents. Chart review revealed moderate amounts of immunization assessment performed by nurses, but virtually no evidence of physicians' orders for immunization., Conclusions: Thus far, there is little evidence that the New Jersey regulation has resulted in a meaningful change in pneumococcal or influenza vaccination practices.