OBJECTIVE To assess the numbers of high-risk adult patients presenting to the emergency department (ED) who have not been vaccinated against influenza or pneumococcal disease and whether emergency physicians are willing or able to routinely provide vaccination. METHODS A survey of patients in the ED considered to be at high risk for morbidity and mortality from influenza or pneumococcal disease; an anonymous, mail-back survey of emergency physicians. METHODS The ED of a university-affiliated hospital with an annual census of 50,000 patient visits. METHODS A convenience sample of adult patients visiting the ED for any complaint who fulfilled the American Thoracic Society and Centers for Disease Control and Prevention requirements as a high-risk patient requiring vaccination with influenza or pneumococcal vaccine. The physicians surveyed were identified from the membership role of the state chapter of the American College of Emergency Physicians. METHODS 1) Influenza and pneumococcal vaccination rates for high-risk patients presenting to an ED during influenza season; 2) reasons for lack of immunization; 3) patient willingness to be vaccinated in the ED; 4) vaccination practice patterns for ED physicians; and 5) reasons why ED physicians are unwilling to give these vaccines. RESULTS 212 high-risk patients were surveyed. 57% and 75% of these patients reported not having received the influenza vaccine and the pneumococcal vaccine, respectively. The main reasons for not being immunized included not being informed they needed it, a prior adverse reaction, and procrastination. Of the unvaccinated patients, 54% were willing to be vaccinated in the ED. Of the surveyed ED physicians, 89% and 93% never or rarely gave influenza and pneumococcal vaccines, respectively. 51% of the ED physicians were willing to give the vaccine. Unwillingness stemmed mainly from: 1) the perception that ED physicians are not primary care providers, 2) inadequate time or personnel; and 3) concerns about adverse reactions or medicolegal liability. Only 5% of the physicians reported organized case-finding mechanisms in their EDs. CONCLUSIONS Significant numbers of high-risk patients who are unimmunized against influenza and pneumococcal pneumonia present to the ED. There is hesitancy among ED physicians about assuming the primary care task of providing such immunizations. Any attempt to institute a large-scale vaccination program in an ED setting needs to be carefully planned in a way to involve primary care providers and to decrease ED physician concerns and reluctance.