the volunteers assuming this risk. The sense of urgency required by national security considerations should be kept in balance with the President’s stated goal of safety. Therefore, learning from experience, making midcourse corrections on every aspect of the program, and maintaining constant and consistent communications with the public are integral to developing the safest program possible. Like all Americans, the committee hopes that the risk of smallpox disease reappearing approaches zero and that an abundance of caution can prevail. Therefore, information on the progress and outcomes of implementation—including but not limited to safety concerns and the experience of states and local communities—needs to be shared, analyzed, and discussed at every step before proceeding further. If the risk of smallpox disease (and thus the benefit of the vaccine) is truly very low, deliberation is key to ensuring the safest program possible.

Issues of Timing

The pre-event smallpox vaccination program is a complicated and enormous task. Given the presidential directive for rapid implementation, the states, major metropolitan areas, and territories charged with developing plans for implementing the first phase of the program had very little time to respond to the guidance CDC issued for developing a program. At the time of the committee’s December 2002 meeting and in subsequent media accounts, several states expressed concern that the original ambitious time frame was not realistic (Young, 2003). Concurrently, CDC revealed that it would relax the 30-day timeline for the first phase of vaccination, but without providing specifics about the changed timeline (CDC, 2002a; Orenstein, 2002; Strikas, 2002). At the time of writing this report, the committee had not received written confirmation of this change.

The committee hopes that local health department and hospital readiness will dictate the launch date for phase I in each state or community, and duration of each state vaccination program. Furthermore, sufficient time should be allowed between the two phases to ensure adequate assessment and plan revision by CDC and its partners at the state and local levels.

Although advising deliberate and careful planning and implementation, the committee recognizes that the unique context of this program may change at any time, as new information about the nature and extent of threats to the public’s health may become available to public health authorities. For example, the confirmation of a suspected smallpox case would immediately signal a change in policy and mandate the rapid implementation of vaccination plans.

As phase I, and ultimately, phase II are completed, it is advisable that CDC evaluate the long-term sustainability of the vaccinated smallpox response teams. There will be some turnover among the first vaccinated

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