vestigation, and response to suspected or confirmed cases of smallpox (also includes the training, communication and relationships noted above, in addition to infrastructure capacity for surveillance, prompt reporting by providers, etc.); and

  1. Protecting the public (e.g., through mass vaccination)—all ingredients described above contribute to the ability of jurisdictions to operate orderly, efficient mass vaccination clinics.

Two additional elements are discussed briefly below to address areas not directly covered by the three elements of preparedness listed above. These include the important role of the health care community in overall public health preparedness and the role of public and media communication.

Preparing Key Responders

The first element of smallpox preparedness described in the CDC/Department of Health and Human Services (DHHS) guidance involves preparing key responders. As the committee noted before, this does not necessarily involve vaccinating workers, but it would ideally include training and education of key responders, and even prescreening for vaccination in the event of a smallpox attack. It is unclear what level of pre-event smallpox vaccination is needed and how numbers of vaccinated personnel relate to the ability to respond effectively to a smallpox attack. This is a decision that must be made in the face of great uncertainty by each jurisdiction before deciding whether to vaccinate additional volunteers and, if so, the number and type of personnel to vaccinate. CDC and its partners have worked to strike a balance between vaccine risk and the benefit of having vaccinated health care and public health personnel pre-event, but it is difficult to determine when the line has been crossed between having insufficient people vaccinated to mount an effective and rapid response and exposing more people than absolutely necessary to a vaccine that is not free of risk, in the absence of imminent threat of disease.

It appears that most jurisdictions have chosen to address this dilemma by cautiously vaccinating at least a small number of volunteers, having apparently concluded that smallpox preparedness is served by having a cadre of vaccinated individuals, typically organized into health care and public health response teams (based either institutionally or regionally), in accordance with Advisory Committee on Immunization Practices (ACIP) recommendations regarding the organization of smallpox response efforts (CDC, 2002d). However, having a number of personnel immune to smallpox and ready to vaccinate, conduct public health investigations, and treat victims is not the sum of preparedness, especially if responders are scattered



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