• develop, implement, and exercise bioterrorism response plans as part of or in addition to their existing emergency preparedness plans;

  • have clear protocols for interfacing with public health authorities (both routinely, such as common infectious disease reporting, and in emergencies, such as the first cases of a suspected outbreak) and for collaborating with other hospitals and health care systems;

  • review and modify institutional policy as needed and call for changes in state licensure and accreditation protocols (Blank et al., 2003);

  • provide ongoing staff training on bioterror agents, including smallpox;

  • develop guidelines for identifying and managing suspicious cases (including suspected smallpox) in their outpatient clinics, emergency departments, laboratories, and other facilities;

  • link with the local or state jurisdiction’s public health preparedness efforts (including the acquisition and distribution of Strategic National Stockpile drugs, vaccines, and supplies, including smallpox vaccine, regionally); and

  • exercise, test, and revise plan(s) as needed.

Although it is essential that public health agencies reach out and collaborate with professional organizations and the hospital industry, such efforts might overlook the increasing number of health care providers in private practices or ambulatory care settings who are not affiliated with professional organizations, but with entities such as the American Medical Group Association or the Medical Group Management Association. The public health community is responsible for finding ways to communicate with and integrate the widest possible range of health care providers in the planning, training for, and testing of smallpox and overall public health preparedness.

Public health agencies also are responsible for strengthening and updating information systems to facilitate disease surveillance and reporting by health care providers, for making efforts to familiarize the health care community with surveillance and reporting procedures, and for providing timely feedback to such reporting and enhancing all communication channels with the health care community, with particular attention to infectious disease experts and primary care providers (Teutsch and Churchill, 1994; Thacker and Stroup, 1994; Baxter et al., 2000; Elliott, 2002). These activities should be coordinated with CDC’s existing internet-based resources.

At the federal level, CDC has conducted many activities to inform and educate providers about smallpox and smallpox vaccination, and these efforts must be sustained over time and must be enhanced to include the knowledge and skills required for a broader kind of preparedness. A range of training and education resources for clinicians are also available from the

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