gram, it is unclear whether the effort succeeded in strengthening preparedness. An early program objective was to build the capacity of every state to vaccinate its entire population within 10 days of a smallpox virus release. Although an ASTHO survey has found that most states believe they are prepared to complete mass vaccination within 10 days and the DHHS secretary has stated that most states “could vaccinate every person … within 10 days, and that’s our goal” (DHS, 2004), there are no data to confirm that states and the nation as a whole would be able to accomplish that. Furthermore, defining preparedness is still a necessity because it is unclear what information has been used to determine that 10 days was an appropriate target. The window of opportunity for smallpox prophylaxis is believed to be 3-4 days after exposure (CIDRAP and IDSA, 2004). If so, aiming to vaccinate all within 10 rather than 3 days would probably be insufficient for the prevention of next-generation cases if exposure were widespread—and certainly insufficient to avert public concern about whether everyone can obtain protection if needed.

After nearly 2 years of great effort, considerable expenditures, and the smallpox vaccination of nearly 40,000 people, the nation remains with insufficient evidence that it is prepared to respond to a smallpox virus release. In fact, the delay evidenced in the response to the monkeypox outbreak (CDC was informed of the outbreak 13 days after its start), which could be considered a proxy for a bioterrorist attack, indicates that considerable gaps in preparedness remain (Mitchell, 2003).

The committee recommends that, in collaboration with its state and local partners and in the context of broad bioterrorism preparedness, CDC define smallpox preparedness; set goals that reflect the best available scientific and public health reasoning; conduct regular, comprehensive assessments of preparedness at the national level and by state; and communicate to the public about the status of preparedness efforts.

This will inform and reassure Americans about the public health system’s ability to protect their health and will help jurisdictions continuously improve and learn from the process of preparing for public health emergencies, including smallpox virus release.

CONCLUDING OBSERVATIONS

Trust is a unifying theme among the committee’s findings. The committee asserts that a relationship of trust between CDC and the public health and health care communities is a critical requirement in the implementation of biopreparedness programs. When a policy has the potential to greatly affect the public’s health, an explanation of the evidence base and rationale that led to the policy becomes necessary to justify and mobilize public



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