ing smallpox victims, training on smallpox diagnosis, treatment, and infection control measures was conducted, and plans were put in place to rapidly vaccinate hospital staff in a post-event scenario. The committee believes that Virginia Commonwealth University Health System’s smallpox preparedness activities provide a good example of how an organization or jurisdiction can be well prepared to respond to a smallpox attack without necessarily having workers vaccinated pre-event.

CDC’s initial attention to the numerical targets so well publicized in the media may have contributed to confusion and concern about goals and outcomes among the public health and health care communities, as well as in the general public (ASTHO, 2003; Connolly, 2003a; ENA, 2003; GAO, 2003; Russell, 2003; Solet, 2003). It has not been made completely clear to most audiences how national estimates of numbers of vaccinees were derived and how they relate to the publicly available threat assessment and to smallpox preparedness. Although the committee recognizes that the CDC has publicly acknowledged that preparedness is not about numbers (see page 1), it is clear that there is lingering confusion about the vaccination program’s aims. This confusion is reflected in recent media reports that characterize the program as having fallen short of its goals (Connolly, 2003a; Snowbeck, 2003)—when comparing the fewer than 40,000 vaccinees in early July 2003 (CDC, 2003l) to the initially publicized target of vaccinating approximately 500,000 and 10 million individuals, in the first and in the second rounds of vaccination, respectively. There also is lingering confusion about how the 500,000 estimate described by CDC related to the 15,000 estimate cited by the ACIP in June 2002 (AAFP, 2002; CIDRAP News, 2002; Manning, 2002). Public confidence and clarity about preparedness efforts would likely be enhanced if the CDC explained how and why it came to view its earlier benchmarks as less than helpful (e.g., were early estimates of vaccinee numbers the upper bounds of what was needed for an effective response to a smallpox attack?). Given that CDC supports ongoing smallpox immunization (CDC, 2003m), there should be clarification about the goals and objectives being pursued (IOM, 2003c) to help reconcile the apparent incongruity between the claim that preparedness is “not about a number” and the stated intent to move forward with vaccination to ensure there are “enough people … immunized” (CDC, 2003i). What number of vaccinees is needed for preparedness? Vaccinating many more than the number needed may waste precious resources that could be utilized to prepare against other threats to the public’s health. Vaccinating fewer than what is needed to respond effectively and rapidly may leave the public vulnerable and unprotected.

The recent severe acute respiratory syndrome (SARS) and monkeypox episodes have provided CDC the opportunity to once again demonstrate its authoritative voice and competence as the nation’s public health leader.

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