importance of working to attain a level of smallpox preparedness and not simply focusing on numbers of vaccinated individuals. Since then, CDC officials have remarked that the smallpox program is “not about a number, it is not about should we have 40,000 people or 400,000 or 4 million people…. It’s about how do we get prepared” (CDC, 2003i). Furthermore, CDC plans to conduct an assessment of its smallpox preparedness efforts and recommend program adjustments to emphasize education and training and ways to facilitate reporting and test readiness (Connolly, 2003b).

The report is organized into three main sections: (1) Integrating Smallpox Preparedness into Overall Public Health Preparedness; (2) Vaccination of Members of the General Public Who Insist on Receiving Smallpox Vaccine; and (3) Selected Aspects of Smallpox Vaccination Program Implementation.


State health departments have been actively involved in planning and preparing for the possibility of a bioterrorist event. We are now seeing that this level of preparation can also assist in unexpected natural outbreaks.

Tommy Thompson, Secretary of the Department of Health and Human Services, in reference to the monkeypox outbreak (CDC, 2003a)

The discussion of integration of smallpox preparedness into overall public health preparedness is organized around four main topics: (1) Challenges in Defining and Assessing Public Health Preparedness; (2) Elements of Preparedness; (3) Testing Preparedness; and (4) Sustaining Smallpox and Overall Public Health Preparedness.

Challenges in Defining and Assessing Public Health Preparedness

There is significant agreement about the difficulties and flaws that characterize the public health infrastructure, and in the last 2 years there has been considerable discussion about the need for public health preparedness. Public health system leaders know the system is not sufficiently prepared based on the way it has responded to a number of threats and crises in recent years. However, the public health system is still in the early stages of developing consensus on defining preparedness and identifying evidence-based standards for planning for and evaluating preparedness. At a minimum, public health preparedness requires adequate and sustained funding based on priorities supported by evidence and a strong public health infra-

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