Over the 15 months between September 11, 2001, and the announcement of the smallpox vaccination policy on December 13, 2002, CDC, other government agencies, public health organizations, and other interested professional groups had extensive and productive interactions that led to the development of smallpox response plans and the discussion of strategies to prepare for a potential smallpox threat (Alliance for Health Reform, 2002; ASTHO, 2001; McIlroy, 2002). For example, the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials, the American Public Health Association, the Association of Public Health Laboratories, and the Council of State and Territorial Epidemiologists (CSTE) interacted regularly to discuss needs and strategies for bioterrorism (including smallpox) preparedness and urged the federal government to focus on increasing bioterrorism preparedness and to improve public health infrastructure funding (ASTHO, 2002). ASTHO also testified about public health preparedness on October 3, 2001, before the Senate Subcommittee on Labor, Health and Human Services, and Education Appropriations (ASTHO, 2001). At that hearing, ASTHO recommended that a national plan be developed for responding to a smallpox virus release, including vaccine delivery and administration.

Shortly after the 2001 attacks, CDC took steps to strengthen its internal smallpox response capacity by forming 20 multidisciplinary smallpox response teams of 10 persons each and vaccinating them (ACIP, 2002; Altman, 2002a). CDC also adopted a two-pronged approach to strengthening the ability of the nation’s state and local public health agencies to respond effectively to a smallpox virus release: pre-event planning and activities (largely involving the advance vaccination of specific types of personnel who would respond to an attack) and post-event planning and activities, pertaining to the personnel, resources, facilities, and capabilities necessary for effective response. The present Institute of Medicine (IOM) committee was charged with providing guidance to CDC on subjects related to the pre-event smallpox vaccination program, and this task has been the committee’s main focus. Therefore, the present report briefly mentions post-event planning only as part of the setting for the smallpox vaccination program and smallpox preparedness in general.

On November 21, 2001, CDC published the federal Post-Event Smallpox Response Plan and Guidelines and forwarded it to state and local