care systems to respond, and plans to protect the public’s health. Also, community leaders and opinion leaders have been shown to have an important role in communicating with the public in a crisis (DiGiovanni et al., 2003). Such individuals should be included in communication plans and their roles well-described before a potential emergency.

Testing Smallpox and Public Health Preparedness

Evaluating the readiness of public health and health care systems to mount an effective response is challenging and requires a clear standard and indicators of preparedness to test against (as noted above) and tools with which to test preparedness. Helpful ways to examine and test preparedness systematically might include: (1) building hypothetical scenarios; and (2) analyzing the public health response to real-life situations such as recent outbreaks, as analogous, though perhaps on a different scale, to future potential threats.

Using Scenarios to Test Preparedness

Many types of smallpox attack scenarios could be developed to aid in exercising and testing preparedness. There are multiple variables to be considered, from ways in which the disease may be introduced, number of initial contacts, pattern of spread and number of geographical areas hit—just a few examples of the vast range of unknowns. What is the duty of the public health system in the face of such great unknowns, and what tools are available to help develop the capacity to respond to all or many possible scenarios?

Although no centralized collection or database of smallpox (or other public health threats) scenarios exists at this time, there are a number of related resources, including the Columbia University collaboration with the National Association of County and City Health Officials (NACCHO) in the Public Health Ready project (developing standards for planning and evaluating public health emergency scenarios), the NACCHO CD-ROM for scenario building, and expertise available from DoD (Columbia University School of Nursing, 2003; NACCHO, 2003a). The committee recommends that CDC facilitate the development of a range of scenarios for potential smallpox attack(s), including one or more multi-threat scenarios, and urge states to use these to expand and continuously improve their plans to respond to a wide range of possibilities. The committee offers its assistance in conceptualizing these scenarios, should such advice be needed.

For each scenario that is developed, state and local jurisdictions could assess their personnel and training needs, their infrastructure requirements (including legal authority), their communication plans and messages, the



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