changes and revisions were made before they proceeded with vaccination, in part to avoid the difficulty of implementing changes midcourse (ASTHO, 2003; Pezzino, 2003).

  1. Overall smallpox preparedness. Third, vaccination is not a goal in itself, but a component of overall smallpox preparedness. Therefore, a pause is needed to re-evaluate the vaccination program’s implications for and integration into overall smallpox preparedness nationally and locally (i.e., to determine what level of pre-event vaccination is needed, and what personnel should be vaccinated to play specified roles in smallpox response).

Some issues to be addressed before deciding whether and how to proceed with vaccination include tasks to be accomplished in the short-term, before moving on to new types of vaccinees:

  • The completion of an in-depth analysis and investigation of all known serious adverse events to date and possible risk factors;

  • The determination of what numbers and types of vaccinated personnel are needed to achieve preparedness;

  • The update of educational and training materials by CDC;

  • The revision of program data systems to include new types of vaccinees and to account for differences in data entry anticipated in expanding to a wider range of occupational contexts and personnel; and

  • The development of guidelines regarding vaccine “take” readings, vaccination site checks and site care, and other issues related to vaccination follow-up of new types of vaccinees.

There are also tasks to be addressed on an ongoing basis and that are also significant to smallpox preparedness in general:

  • The establishment of communication and collaboration with other partners (e.g., first responders, security personnel, health care and hospital systems, community-based health care providers);

  • The revision by state and local programs of response plans that lay out clear roles and activities for teams responding to a potential event; and

  • The need for strategic planning and reconciliation of the smallpox vaccination program with other bioterrorism programs and other public health priorities.

A break in the course of the vaccination program may help prevent vaccinating potentially large numbers of additional volunteers (e.g., health care workers, traditional first responders, and others) less safely than in the first phase of vaccinations, without adequate time to implement or update safeguards (e.g., screening, training and education) that would be appropriate to new types of vaccinees and their contacts.

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