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The Smallpox Vaccination Program: Public Health in an Age of Terrorism (2005)

Chapter: Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5

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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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F
Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation, Letter Report #5

December 19, 2003

Dr. Julie Gerberding

Director

Centers for Disease Control and Prevention (CDC)

1600 Clifton Road, NE Atlanta, GA 30333

Dear Dr. Gerberding:

The Committee on Smallpox Vaccination Program Implementation is pleased to offer you the fifth in a series of brief reports providing timely advice to assist CDC in preparing for a potential smallpox emergency. CDC asked the Institute of Medicine (IOM) committee to review CDC’s smallpox readiness indicators, which are part of a larger set of public health emergency preparedness indicators being developed through the Public Health Preparedness Project.1 The IOM committee reviewed the smallpox readiness indicators and heard from panelists representing public health, health care providers, health care institutions, and first responders at its

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CDC has used the terms “readiness” and “preparedness” relatively interchangeably in their description of the goals, purpose, and implementation of the Public Health Preparedness Project. Accordingly, the committee also has used both terms to describe essentially the same concept throughout this report.

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

November 6, 2003, meeting and offers this report based on the information gathered at that meeting and during its ongoing assessment of the smallpox vaccination program.

INTRODUCTION

The committee commends CDC for communicating more clearly that the focus of the smallpox preparedness effort is on all components of smallpox readiness (e.g., preparedness, detection, response,2 containment, and recovery). Development of the smallpox readiness indicators—and the overall public health preparedness indicators—has helped to put preparedness for one hazard (e.g., smallpox) into the context of all-hazards public health preparedness. By planning to use the public health preparedness indicators to assess readiness and establish a baseline during the first year of their use, CDC has helped cast preparedness within the broader work of public health.

The committee also applauds CDC for responding to the needs of state and local public health agencies by beginning the development of smallpox—and overall public health emergency—preparedness indicators. CDC’s state and local partners have stated that they need assistance in determining what constitutes a minimum level of preparedness (Selecky, 2003) and the most likely scenarios for which they should be preparing. The IOM committee echoed these concerns in its second report by encouraging CDC to define smallpox preparedness and to work with states to decide what more is needed to achieve smallpox preparedness (IOM, 2003a), and again in its fourth report by recommending that CDC assist states in establishing a baseline level or minimum standard of smallpox preparedness (IOM, 2003b). CDC has begun important work in this area by launching the Public Health Preparedness Project to ensure national preparedness for bioterrorism. The committee commends CDC for aiming toward indicators that will help state and local public health agencies document their progress on preparedness.

Description of the Public Health Preparedness Project

CDC has long recognized the importance of preparedness for bioterrorism and other public health threats. Prior to September 11, 2001,

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In this report, the committee uses the terms “response” and “respond” to mean all the activities that are necessary following identification of an infectious disease outbreak or bioterrorism event (e.g., epidemiologic investigation, activation of communication plans, implementing mass vaccination plans, enhanced surveillance, etc.).

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

CDC had awarded over $120 million to state and local public health agencies to support bioterrorism preparedness and response activities (CDC, 2003a). Through the Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism (Program Announcement 99051) (hereafter, referred to as the “CDC cooperative agreement”), CDC awarded $918 million in fiscal year 2002 and $870 million in fiscal year 2003 (with an additional $100 million for smallpox preparedness) to support state and local agencies’ bioterrorism preparedness activities.

In the past 6 months, CDC has launched the Public Health Preparedness Project to help define a baseline level of public health preparedness and to assess how states are using the funds received through the CDC cooperative agreement. The goals of the Public Health Preparedness Project are (Henderson, 2003b):

  1. Define and establish a fundamental level of public health preparedness—initially associated with the CDC bioterrorism preparedness and response cooperative agreement program.

  2. Serve as the basis of score-carding state and local preparedness.

  3. Provide the framework for the fiscal year 2004 cooperative agreement guidance;.

  4. Assist in identifying technical assistance needs of state and local public health agencies.

At the time of the November meeting, the score cards were intended to be used for identifying states’ gaps in preparedness and areas where more resources are needed and were not intended to be used to reduce funding to states that are not performing as well as others (Henderson, 2003a). The committee endorses this view and believes that it is important that the score cards be used as opportunities for improvement.

In developing and implementing this project, CDC has made the following assumptions (Henderson, 2003a):

  • It is important to focus first on bioterrorism and other infectious disease outbreaks, and then on chemical and radiological/nuclear terrorism.

  • Flexibility is needed to address jurisdictional variability.

  • Little science-based evidence exists for clear-cut criteria.

  • Current resources may not be sufficient to fully address indicators.

  • State and local health agencies have primary responsibility for assuring community capacity.

After an internal CDC workgroup, an external workgroup of national stakeholders, public health partners, and the IOM committee (through this report) provide feedback on the 4 goals, 22 objectives, and 127 indicators,

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

CDC will pilot test the indicators at five cooperative agreement recipient sites and some local health jurisdictions (Henderson, 2003a). Revisions will be made based on the pilot testing. In the summer of 2004, CDC will begin state and local assessments (based on the indicators) to establish a baseline, against which states will be assessed in subsequent years (Henderson, 2003b).

Committee Tasks

CDC asked that the IOM Committee on Smallpox Vaccination Program Implementation address the following tasks in their deliberations after the November 6, 2003 meeting (Henderson, 2003b):

  1. Review the smallpox readiness indicators to determine if they are appropriate in assessing smallpox preparedness;

  2. Develop/identify criteria or evidence that could be used to qualify a “Yes” response to a smallpox readiness indicator; and

  3. Develop a smallpox case study/scenario (addressing jurisdictional variability) that can be used to test the relevance of the smallpox readiness indicators.

In the first task, the committee was asked to focus on a subset of 10 smallpox-specific indicators within the full set of 127 indicators and also to consider smallpox-related indicators from the larger set. In the report text, the committee makes some general observations about the entire set of all-hazards public health preparedness indicators. In Appendix 5-A, the committee offers specific comments about the 10 smallpox indicators and some criteria to aid in validating “yes” answers to the questions asked by the indicators (second task). The third task is addressed below.

GENERAL PARAMETERS OF FOUR SCENARIOS TO ASSESS SMALLPOX READINESS INDICATORS

Utility of Smallpox Scenarios
Learning from Real-Life Experiences and Hypothetical Scenarios

There are aspects of all-hazards public health preparedness that are hypothetical, because the nation has not experienced smallpox or certain other types of bioterror attacks, and the range of potential agents, extent of attack or outbreak, locations, and other variables are nearly limitless. Nevertheless, there are at least two ways to develop a useful framework for conceptualizing public health emergency response activities: designing sce-

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

narios that illustrate what could happen, and examining responses to real-life public health crises that have occurred already. Scenarios and real-life experiences help program planners consider the range of possibilities and complications that must be considered and addressed when responding to a public health emergency.

Some recent public health challenges highlight how real-life lessons can help inform future planning activities and the development of scenarios to test and improve planning (IOM, 2003b). The anthrax attacks of October 2001 underscored that successful mass prophylaxis activities are dependent upon clarity of mission, clear eligibility criteria for prophylaxis, well-defined lines of authority and responsibilities, effective communication, collaboration among all agencies involved in a response, and coordination of staffing and supplies (Blank et al., 2003). The emergence of Severe Acute Respiratory Syndrome (SARS) in early 2003 suggests that even though the modes of transmission of a virus may not be understood fully, health care workers will report to work if health care administrators institute procedures to maximize the safety of health care workers (Emanuel, 2003). The monkeypox outbreak in the summer of 2003—and the 2-week delay in reporting the first case to public health authorities—reminded the public health community that more work is needed to educate health care providers about when and how to report unexpected infectious diseases, and that overall communication between the health care and public health communities needs to be improved (Edmiston et al., 2003; MacKenzie, 2003). These recent public health challenges illustrate the range of issues that must be considered when designing detailed scenarios to help guide planning efforts.

Purpose, Development, and Use of Four Smallpox “Scenarios”

At the November 6, 2003, committee meeting, CDC asked the committee to develop a smallpox case study/scenario (addressing jurisdictional variability) that can be used to test the relevance of the smallpox readiness indicators (Henderson, 2003b). Accordingly, the committee developed four smallpox “scenarios” (described in detail below) that it used as an organizing framework for assessing the 10 draft smallpox readiness indicators and developing their subsequent evaluative criteria.

In developing these “scenarios,” the committee recognized that these are not detailed scenarios that can be used for broad planning purposes but, rather, are general parameters of scenarios that are only meant to be used for the committee’s purpose—to help test the draft smallpox readiness indicators. The simple descriptions of four smallpox contingencies that the committee has laid out below could be called many things—scenarios, case studies, vignettes. For the sake of simplicity, the committee decided to use

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

the term “scenario,” though recognizing that the descriptions below are mere sketches and at most can be called general parameters of smallpox scenarios.

Due to time limitations and their limited purpose, these particular scenarios are simply four possible situations, and the activities that would need to receive particular attention in each scenario. These scenarios were chosen because they represent a range of possible situations, without focusing on the extremes (i.e., assuming that there is zero risk of a smallpox attack or assuming that smallpox will infect every single person in the United States). Should CDC and its partners deem these four scenarios a useful starting point, providing an illustrative range of smallpox contingencies, more work would be needed to fill in the details to lead to more elaborate scenarios that are useful for conceptualizing the federal, state, and local response to a smallpox outbreak. As described in previous reports (IOM, 2003b), the committee believes that detailed smallpox planning scenarios are necessary to assist states in planning their response activities and evaluating their level of preparedness. If CDC intends to use scenarios as a planning tool, the committee recommends that the scenarios represent a range of possible situations, be used to help guide state and local planning activities, and facilitate state and local assessment of their level of preparedness.

Description of Smallpox “Scenarios” Used to Assess Readiness Indicators
Scenario #1: No smallpox case(s)/known presence of virus
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This scenario assumes that preparedness activities continue, with no new data on degree of risk (most recent statement from the President about risk: “no information that a smallpox attack is imminent” [White House, 2002]). This scenario can be thought of as the “maintenance state,” and would also include any false alarms (i.e., pseudo-case). For this “no case” scenario, state and local public health agencies would need to focus, in particular, on training, vaccinating new members of response teams due to turnover, surveillance, planning, exercises, public information for false alarms, and clear lines of authority for decision-making.

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By “known presence of virus,” the committee means the existence of the smallpox virus (i.e., in a vial or in the environment) outside of the two laboratories in the U.S. and Russia with known secured stocks of the smallpox virus.

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
Scenario #2: Limited number of confirmed smallpox case(s)/known presence of virus outside United States

This scenario assumes that one or a very limited number of confirmed smallpox cases have been identified somewhere in the world, but there is no immediate evidence of cases in the United States. For this scenario, state and local public health agencies would need to focus, in particular, on criteria for deciding if, when, and how strongly to encourage vaccination of the general public, communication with the public, risk communication, enhanced surveillance (including surveillance by clinicians), laboratory capacity, and plans for enhanced clinical capacity.

Scenario #3: Limited number of confirmed smallpox case(s)/known presence of virus in United States, outside of own jurisdiction

This scenario assumes that one or a very limited number of confirmed smallpox cases have been identified somewhere in the United States, but there is no immediate evidence of cases in the particular jurisdiction. For this scenario, state and local public health agencies would need to focus, in particular, on enhanced surveillance (particularly focusing on travel hubs), communication with the public, risk communication, decision-making about distribution and delivery of vaccine, enhanced clinical capacity, enhanced laboratory capacity, interjurisdictional issues, and anticipation of legal issues.

Scenario #4: Multiple confirmed smallpox case(s)/known presence of virus in multiple U.S. jurisdictions, with at least one case in one’s own jurisdiction

This scenario assumes that multiple confirmed smallpox cases exist in multiple U.S. jurisdictions, with at least one confirmed case in the local jurisdiction. For this scenario, state and local public health agencies would need to focus, in particular, on frequent communication with the public, risk communication, close working relationships with the media, shifting legal authority among federal, state, and local entities, decision making about distribution and delivery of vaccine, clinical capacity, laboratory capacity, plans for disposal of human remains and coordination with Disaster Mortuary Operational Response Teams (DMORT), and recovery plans.

Caveats to Consider in Proposed “Scenarios”

Even though bioterror agents differ in important ways, many preparedness activities will be the same, no matter what the specific agent is. Whereas

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

scenarios for different agents will require some activities unique to that particular agent, scenarios reflecting a continuum of possibilities for one agent (e.g., smallpox) will require escalating activities.

Detailed smallpox planning scenarios that represent the range of response activities that might be necessary could help state and local jurisdictions assess how this range of activities correlates to different levels of preparedness. It is important to recognize, however, that a real-life event probably is not going to proceed exactly according to any of the simple “scenarios” proposed by the committee, or more detailed scenarios yet to be developed. For planning purposes, communities will have to assess the pace at which they can respond to the different situations represented by each possible scenario.

The committee recognizes the value of also developing scenarios for other threats (e.g., anthrax, botulinum toxin, chemical attacks), but due to the scope of its charge, it only offers comments on smallpox scenarios that can be used for assessing the readiness indicators. The embedding of smallpox within an all-hazards approach also means that some of what might be considered smallpox preparedness (e.g., mass vaccination clinics) is really a specific example of a more general response (i.e., mass distribution of any vaccine, prophylaxis, or medication). Irrespective of specific scenarios that may be chosen eventually, the committee believes that the number used by state and local agencies should be relatively small, so that the multitude of specific details for the set of scenarios does not confuse planning activities and even detract from preparedness. Meta-scenarios that transcend individual bioterror agents—and address the possibility that two or more public health emergencies may occur at the same time—may be needed, and their use would reinforce the all-hazards approach to preparedness.

Applicability of Scenarios to Specific Local Circumstances

The committee used the general parameters of smallpox scenarios described above to evaluate the smallpox readiness indicators. If scenario parameters such as these are used as a starting point for developing detailed smallpox scenarios, state and local jurisdictions will have to use some judgment in determining to which scenario they want to apply their jurisdiction’s limited resources. For example, some may say that it would be imprudent for jurisdictions that have already experienced a terrorist attack (e.g., New York City, Washington, DC, area) to assume that a smallpox attack in their community is not a possibility, whereas others may say that it would be ill-advised for a small, rural, Midwestern town with numerous other public health problems to assume that a smallpox attack in their community is a high probability and put all their resources into preparing for this scenario. A whole range of scenarios is possible for any community,

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

but it will be the role of state and local health departments, local boards of health, and communities to assess the possible scenarios and decide how they want to allocate public health and bioterrorism preparedness funds. No matter where an attack initially occurs, it can spread to other areas, so communities will need to consider how they would respond to such an event.

Little Variability in Types of Planning Activities Across Scenarios

The general parameters of four scenarios that the committee used to assess the smallpox readiness indicators highlight key differences in the scope of response activities—the pace of the response, the overall timeline for accomplishing response activities, supplies and personnel that are readily available—but in terms of the planning activities that are required before the event, most of the same activities are needed.

By examining the 10 proposed smallpox indicators, the committee determined that most of the indicators deal with planning activities that would be required of any community should smallpox appear anywhere in the world (e.g., enhanced surveillance, preparations for increased laboratory capacity, more frequent and widespread communications, expanded education and training). Even the indicator addressing the activation of mass vaccination clinics shows little variability in terms of planning activities across the four scenarios (except for the “no cases” scenario) since CDC has stated that a case of smallpox anywhere in the world would lead to a decision to offer mass vaccination to the public (Henderson, 2003b). The main variability in planning that emerges across scenarios is for those indicators that are related to the response to a case in one’s own jurisdiction (e.g., activation of quarantine and isolation procedures, designation of medical surge capacity sites).

Since it would not be prudent to only plan for the “no case” scenario, most communities will find that most of the readiness indicators are applicable to a majority of their planning activities. However, variability does exist in the response activities that would be required for different scenarios. If any of these scenarios occurs, the actions needed for that particular situation, the time frame in which those actions will need to be accomplished, and the resources that will be required for the response will be very different from what is required for another scenario.

Applicability of Scenarios to Decision-Making and Management Structure of a Smallpox Response

Although the four smallpox scenarios described above (or any range of scenarios) may be of limited utility for differentiating planning efforts that

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

must take place prior to an event, scenarios are useful tools for designing a decision-making and management structure for a smallpox response. Scenarios provide a framework for characterizing the decisions that will need to be made once a smallpox case is identified and the range of decisions that will be necessary, depending upon the circumstances of the outbreak.

Since decisions will need to be made rapidly once there is evidence of a smallpox outbreak, a decision-making and management structure should be agreed upon by federal, state, and local entities before an event—when there is time to consider the options and generate support for the planned decision-making process—so that all parties involved understand how decisions will be made post-event and precious time will not be wasted on process issues. Such a decision-making and management structure should specify how the stages of the progression of the outbreak will be defined and, at each stage, who will make the key decisions, who will be the spokesperson, who will advise those decisions, who will be consulted, who will be informed of the decision, and what types of external validation and advice will be needed. A decision-making and management structure for a smallpox outbreak also should specify the criteria that will be used to decide: if, when, and how strongly to encourage vaccination of the general public; the necessary speed of vaccination activities; when to close social institutions (e.g., schools, public transportation, workplaces) for epidemic control; and when and how to institute isolation and quarantine procedures. By having these decision-making and management process issues specified a priori, the likelihood of confusion, public mistrust, delay, and rushed decision-making will be reduced.

Although it is outside state and local agencies’ purview to plan for a nation-wide smallpox emergency that would affect all corners of the country and all segments of the national infrastructure (and the committee chose not to test the smallpox readiness indicators against such a catastrophic scenario), it is important for the federal government to create the necessary linkages across all federal agencies for such a possibility (this could be an extension of the Federal Response Plan coordination activities, with a focus on smallpox).

Pandemic influenza planning is characterized by many of the same decision-making challenges, and any work on these decision-making issues for pandemic influenza planning that could assist smallpox response planning should be utilized. The swine flu event of 1976 provided important lessons and insights into the complications and nuances of responding to an infectious disease outbreak. Since a smallpox outbreak would share many of the characteristics of an influenza pandemic (e.g., surprise emergence, need for vaccination, importance of communication to the public), many of the same guiding principles for decision-making would apply to both types of incidents. The swine flu incident underscored that decision-making dur-

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

ing this type of infectious disease outbreak must be incremental and science-based, flexible, designed for efficiency and speed, show clear lines of authority, and have public acceptance (Neustadt and Fineberg, 1978).

Because it is impossible to foreshadow the exact circumstances of a smallpox outbreak, the committee recommends that a flexible, incremental, science-based decision-making and management structure for smallpox response that includes all levels of government be developed and communicated to state and local agencies so that the consequences of a smallpox outbreak can be managed effectively.

Key message #1:

Preparedness must include a greater emphasis on planning, management, and decision-making.

COMMENTS ABOUT THE DRAFT READINESS INDICATORS

The committee reviewed CDC’s draft readiness indicators and at its November 2003 meeting received thoughtful input from representatives of the public health, health care, and first responder communities. A significant proportion of the testimony complemented many of the committee’s own observations—that some readiness indicators seem unevenly matched (with some very broad and others too detailed and minor), that there is an unnecessarily large number of indicators, and that some indicators are redundant or could be condensed. Furthermore, the committee discussed the issue of score-carding vis-à-vis the greater principle of continuous quality improvement, the purpose of the indicators, a framework for the indicators, and several important elements of preparedness that are underrepresented if not completely overlooked in the indicators.

Due to time limitations and because the broader set of all-hazards indicators was still under development, the committee chose not to conduct a “big picture” determination of whether the 10 smallpox indicators are true predictors of smallpox preparedness. The committee did not systematically discuss the full scope of what is required for smallpox and overall preparedness, except to acknowledge that measuring preparedness requires asking “prepared for what?” and hence implies the need for scenarios. Nevertheless, the committee had some detailed comments about each of the 10 smallpox indicators, as described in Appendix 5-A. Committee members also identified important areas initially included in the CDC planning materials and cooperative agreement guidance, but not evident within the larger

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

set of indicators and offers these areas (described below) for consideration as CDC refines its readiness indicators. Furthermore, the committee outlined four scenarios (described above) and the various capabilities needed in each case—an exercise which helped the committee draft some criteria (see Appendix 5-A) to help document “yes” answers to the 10 smallpox indicators and ensure well-rounded assessment of jurisdictions’ capabilities in areas identified by the current indicators.

Continuous Quality Improvement

Measuring preparedness should be characterized as a process of continuous quality improvement within the public health system (CDC, 2003c) rather than a way to focus on shortcomings in states’ capacities. The readiness indicators themselves should be subject to the process of continuous quality improvement (in relevance and validity), as they are not static but could be expected to change with time as the Public Health Preparedness Project evolves.

Although CDC has stated that it does not intend that the indicators be used in a punitive fashion (Henderson, 2003a), some panelists perceived the notion of score-carding as potentially intimidating to jurisdictions and not necessarily reflective of quality performance and preparedness (Dunn, 2003; Schulman, 2003). Also, in a process of developing an entirely new measurement tool to be used in widely divergent settings and requiring many subjective judgments, using a reporting device (e.g., a red to green spectrum) that suggests precision is probably an error. Any version of a numeric or color-coded scale such as that illustrated in the CDC presentation to the committee seems premature. The use of Likert-type scales is probably appropriate, and the CDC is encouraged to look at the four-level scale already in use in the state and local public health performance indicators as a model (CDC, 2003b, 2003d). Any type of overall score should be similarly based on a common public health framework, which is discussed on subsequent pages.

The committee heard from panelists that yearly assessments of states’ bioterrorism and infectious disease preparedness capacities could become a burden. Many assessment and accreditation programs acknowledge this in their routine use of reviews on a multiyear cycle (e.g., Joint Commission on Accreditation of Healthcare Organizations hospital accreditation, health professional education accreditation). In order to ease the resource strain on grantees and to more clearly separate measures of compliance from measures of preparedness, the committee recommends that CDC consider conducting the preparedness assessments on a multiyear basis (e.g., every 3 to 4 years).

Concise evaluations of grantee compliance with cooperative agreement

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

requirements could be conducted yearly to provide more frequent assessments of grantee accountability to policy makers and communities.

Key message #2:

Readiness to respond to public health emergencies (including smallpox emergencies) should be part of overall continuous quality improvement of the public health system.

Purpose of the Indicators
A Dual Purpose in Developing Indicators

In its review of the readiness indicators, the committee noted (and also was informed by CDC [Henderson, 2003b]) that the purpose of the indicators is two-fold: to measure grantees’ compliance with the CDC cooperative agreement guidance, and to measure grantees’ preparedness to respond to public health threats. This duality of purpose is a cause of concern to the committee, as it may lead to having an overly large set of indicators and to using indicators that are not indicative of preparedness. Although the two purposes—compliance and preparedness—are valid and related, one addresses an immediate need, focused on line items to be met by grantees (e.g., meetings held, number of workers trained), while the other is a longer process, focused on outcomes.

The indicators developed to address the immediate need of measuring compliance with the CDC cooperative agreement will accomplish some, but not all, of what is needed for a longer, ongoing assessment of the scope of federal, state, and local preparedness activities. The committee recommends that CDC address its immediate need of measuring cooperative agreement compliance with a concise and simple set of indicators, and then use this set of indicators as the foundation of a longer, deliberative, national process to develop measures that address the full range and appropriate balance of preparedness activities.

Distinct Indicators Needed for Federal, State, and Local Jurisdictions

Further questions about the purpose of the indicators ask whose preparedness is being evaluated and whose accountability is being assessed. Most indicators refer to “local and/or state agency” but the committee was

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

unsure whether “local” referred to the four local jurisdictions funded by CDC or to local public health agencies funded in turn by states. The public health panel that addressed the committee at its meeting recommended, and the committee agreed, that there should be separate indicators (or sets of indicators) for local and state jurisdictions (Plough, 2003; Williamson, 2003). It is imperative that the indicators distinguish among the roles of the federal government, states, or local jurisdictions. The indicators should distinctly identify the specific activities for which local jurisdictions are responsible and the specific activities for which states are responsible.

The federal government also needs to be held accountable for its preparedness activities. The federal government and CDC, specifically, are responsible not only for assisting state and local jurisdictions in their preparedness activities and monitoring their progress, but also for carrying out certain activities that must be accomplished at the federal level. The CDC has some unique responsibilities in national smallpox preparedness (e.g., developing a vaccination priority list for the nation, working with FDA for provisional use of smallpox vaccines still under Investigational New Drug protocols, and establishing decision-making and management processes). The role of CDC in national preparedness must be laid out clearly so that state and local jurisdictions have clear assurance of the federal public health resources that will be available in an emergency. The committee recommends that federal agencies and CDC, specifically, be held accountable for their unique federal responsibilities in an emergency response and assessed on their progress in facilitating national public health emergency preparedness.

Key message #3:

CDC should address its immediate need of measuring cooperative agreement compliance with a concise and simple set of indicators, and then use this set of indicators as the foundation of a longer, deliberative, national process to develop measures that address the full range and appropriate balance of preparedness activities.

Key message #4:

Federal agencies bear unique responsibilities in emergency response, and they should be held accountable and assessed on their progress, similar to their state and local counterparts.

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

BOX F-1
The Essential Public Health Services

  1. Monitor health status to identify community health problems

  2. Diagnose and investigate health problems and health hazards in the community

  3. Inform, educate, and empower people about health issues

  4. Mobilize community partnerships to identify and solve health problems

  5. Develop policies and plans that support individual and community health efforts

  6. Enforce laws and regulations that protect health and ensure safety

  7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable

  8. Assure a competent public health and personal health care workforce

  9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services

  10. Research for new insights and innovative solutions to health problems

SOURCE: CDC (2003c).

A Framework for Readiness Indicators

It was not apparent to the committee what framework was used to develop and structure the readiness indicators and to ensure that there are indicators identified for every major component of preparedness. CDC noted that it is moving away from the focus areas described in the CDC cooperative agreement guidance for FY 2003 (CDC, 2003a) but did not explain what, if any, new framework would be used, and one does not emerge from the indicators document, other than the four chronological goals (pre-event activities; detection and reporting; response and containment; recovery).

The committee recommends that CDC consider utilizing the Ten Essential Public Health Services as a framework for the readiness indicators (see Box F-1). There are several reasons for this recommendation. The 10 essential services are fundamental in identifying the core responsibilities of public health and, therefore, the capacities and resources a public health system needs to be effective. The importance of a strong public health infrastructure for preparedness has been emphasized repeatedly (GAO, 2000; IOM, 2002a; Salinsky, 2002), because preparedness for bioterrorism does not occur in a vacuum but is one component of a public health system

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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capable of maintaining optimal population health against a wide range of current and potential threats. Also, the 10 essential services are a well-established framework widely used by local and state public health agencies in planning and evaluation, and they have served as the foundation for the Department of Justice/CDC Public Health Performance Assessment for Emergency Preparedness (DOJ, 2000), and most important, for the National Public Health Performance Standards (CDC, 2003c), which are used by many public health agencies to measure performance and ensure continuous quality improvement (NACCHO, 2002).

Other sets of indicators could be used to help refine CDC’s readiness indicators process. To ensure reasonable alignment with global preparedness efforts, the World Health Organization’s indicators effort should be reviewed (WHO, 2003). Also, the Department of Health and Human Services (DHHS) Metropolitan Medical Response System (MMRS) program conducted some pioneering work in the areas of multi-sectoral coordination for preparedness, bringing together public health, government, first responders, health care, and others. IOM’s Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report (2001) highlighted the importance of placing the “emphasis on enhancing existing systems rather than building new, perhaps competing [ones]” as a principle of preparedness for chemical, biologic, and radiological terrorism. Using the 10 Essential Public Health Services as a framework for the indicators would reinforce these major structuring principles within the public health system. The IOM review of tools for evaluating the MMRS itself provides some examples of preparedness indicators as well as a comprehensive framework of 23 essential capabilities of preparedness (see Appendix 5-C) (IOM, 2001, 2002b).

Elements Not Reflected in the Readiness Indicators

At its November 6, 2003, meeting, the committee heard from four groups of stakeholders in public health and smallpox preparedness: first responders, health care providers, health care institutions, and the public health community. The panels presented findings from their review of the CDC readiness indicators and focused on areas they considered important to preparedness but were not sufficiently reflected in the indicators: communication, collaboration (in particular, between CDC and the Health Resources and Services Administration), and training and education.

Collaboration and Communication

A recurring theme in the panel presentations is the need for diverse collaborations and the engagement of all relevant stakeholders in the work

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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of preparedness. A closely related theme is communication—among levels of government and the various partners in preparedness, with communities and the general public, and with the media—also an area panelists found missing or severely underrepresented among the indicators, despite the vital importance of effective communication channels and methods in most preparedness activities.

The committee found that, despite the fact that the pre-event guidance emphasized the need for intersectoral relationships among the public health system and the first responder communities (i.e., fire, emergency medical services, law enforcement), the indicators do not reflect this emphasis on collaboration and communication. They contain almost no mention of these important partners in preparedness and little mention of the cross-linkages with health care providers and professional organizations, health care institutions (including, but not limited to, hospitals), and health care insurers. With the exception of a few representatives of the public health community, other partners were not involved in the development of the readiness indicators, although their critical roles in responding to smallpox attack (and other public health crises) were acknowledged and described in earlier planning materials developed by CDC. To remedy these gaps, formal measures of the strength and effectiveness of collaboration could be added to the readiness indicators to assess jurisdictions’ capacity in these important areas.

In recent years, the role of communities in the public health system has been increasingly recognized and supported. With their ethnically and culturally diverse populations, service and social organizations, opinion leaders, and faith groups, communities can contribute knowledge and other resources to the work of keeping the population healthy. Bioterrorism is just one of the threats to the public’s health, and developing purposeful community engagement in preparedness should be part of the range of activities conducted by the public health agencies and their partners. Involving the community in planning and evaluation requires good communication, building partnerships with organizations and community leaders, and including community representatives in decision-making. This investment in counting communities among partners in preparedness also could lead to a better informed citizenry, which may help to decrease the potential for fear and panic in the course of a bioterror event or other emergency.

Risk communication is largely absent from the activities measured by the smallpox readiness indicators. As the committee has emphasized in previous reports, in particular its second report (IOM, 2003a), effective communication is key to preparedness and should include building relationships with the media, designating trained, trusted, knowledgeable spokesperson(s), developing uniform messages, relaying timely and accurate information to the public, and planning communication strategies and

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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materials to respond to a range of contingencies. The response capacity of the public health system and its partners must include communication strategies and activities, and the readiness indicators should measure communication preparedness. If an event were to occur, would the jurisdiction being assessed have the necessary components of a good communication plan in place and ready to implement immediately, or will it appear unprepared, and thus leading to misinformation, panic, mistrust, and ultimately resulting in a failure to mount an effective emergency response? In a smallpox event (or other emergency), hospital communication capacity also may become overwhelmed by requests for information, and therefore would need readily available communication materials, well-known protocols, and well-established linkages to local and state public health agency spokespersons and resources.

Collaboration and Communication Among Federal Agencies with Health Responsibilities

The relationship between CDC and Health Resources and Services Administration (HRSA) parallels the connections between public health agencies at all levels and health care providers in hospitals, health centers, and communities. Although the CDC and HRSA cooperative agreement guidance documents are somewhat analogous, and make references to each other (and include an appendix about cross-cutting activities and benchmarks), it seemed to both the committee and the panelists that the agencies themselves have yet to fully coordinate their preparedness planning and their work on preparedness indicators. In addition to planning and collaboration at the administrative level, frequent and productive communication using efficient and redundant channels is needed to facilitate the exchange of information between the health care and public health communities, to clarify reporting requirements and technical assistance resources, to familiarize all health care providers and public health workers with each other’s roles and capabilities in a smallpox or other emergency, to address unknowns and concerns, and to jointly implement various preparedness activities.

Strengthening surge capacity, discussed below, is an area that requires particular, joint attention from CDC and HRSA, given the interdependence of the public health and health care communities and the need for enhanced familiarity with each other’s unique and interrelated responsibilities (e.g., public health to conduct surveillance, and health care to report suspected or confirmed cases), capabilities (e.g., public health to conduct mass vaccination or distribution of countermeasures, and health care to provide diagnosis and treatment), and resources.

Furthermore, the communication and collaboration between the health

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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care and public health communities and relevant federal agencies should extend to the Centers for Medicare and Medicaid Services (CMS), the Department of Defense (DoD), the Department of Veterans Affairs (VA), the Indian Health Service (IHS), and the Substance Abuse and Mental Health Services Administration (SAMHSA). CMS coordinates the Medicaid and Medicare programs, including developing conditions of participation in the programs. If bioterrorism planning and exercises were included among the conditions of participation in Medicaid and Medicare, this could further hospital preparedness planning. DoD, VA, and IHS operate major health care facilities for specific populations and would likely play vital roles in the health care response to a smallpox attack or other emergency. SAMHSA would be responsible for addressing the need for mental health services arising from a bioterrorism event.

Preparedness indicators are needed to assess the strength, scope, stability, and sustainability of health care–public health linkages. In addition to considering indicators that assess such linkages, the committee recommends that CDC collaborate with HRSA to integrate the preparedness indicators into one document, in order to help the health care and public health communities work hand-in-hand to plan, implement plans, and evaluate their readiness to respond to threats (including, but not limited to, a smallpox attack) and to avoid requiring duplicate reporting from states.

Training and Education

Another component of preparedness not evident among the readiness indicators is the training and education of all workers (including first responders) expected to respond to a smallpox attack or other public health threat. Well-trained personnel are essential to mount an effective response, and training needs range widely depending on the type and functional responsibilities of personnel. This has been discussed extensively in other committee reports (IOM, 2003a). Several related comments about training and education were provided by meeting panelists (see below).

Issues Related to Surge Capacity

Several CDC readiness indicators focus on surge capacity—the ability to rapidly expand facilities (beds), workforce, and other capabilities (diagnostic, treatment, etc.) in response to a crisis, such as a smallpox attack or major infectious disease outbreak. All stakeholders who participated in the November meeting shared concerns about inadequate surge capacity in their respective health care, public health, and first response communities.

Although health care providers and emergency responders may be able to surge briefly in order to handle an acute event, their surge capacity may

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

be limited if sustained effort is required over a longer period. Both the committee and the groups that provided their input at the committee’s meeting identified the need to acknowledge the multiple obstacles to achieving surge capacity and the fact that existing systemic strains and limitations will not be resolved by the influx of bioterrorism funds. The emergency responder communities stated that in a crisis, they would be called upon to continue their usual duties and carry out other functions not necessarily related to public health response (Fischler, 2003). This could limit their ability to help enhance surge capacity for mass vaccination or in other areas. The health care institutions and providers who presented to the committee expressed concern about their ability to contribute to surge capacity when their current resources (e.g., hospital emergency departments, staff) are often overwhelmed by routine needs or even just seasonal spikes (e.g., cases of influenza) (Austin, 2003; GAO, 2003; Temte, 2003).

The surge capacity needs of public health laboratories also require careful consideration, as laboratories confirm diagnoses and conduct essential surveillance functions. It is important that federal and state public health agencies consider the possibility of weaponized smallpox and the need for environmental sampling, as well as the limiting factor of laboratory biosafety level. Furthermore, in a crisis, laboratories share some of the workforce and resource concerns of the public health agencies and health care entities.

Key message #5:

Public health readiness indicators need to address each of the distinct roles of federal, state, and local jurisdictions in the planning for and response to a public health or, specifically, smallpox emergency.

Key message #6:

The current set of readiness indicators provides a useful start to measuring preparedness, but many indicators seem too broad and redundant and not based on any evident framework, such as one common to the public health system.

Key message #7:

The draft readiness indicators do not reflect the significance of active and sustained collaboration and communication among the public health system, the health care system, first responders, and the community (conceived in the broadest sense).

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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Selected Gaps and Needs of Public Health Preparedness Identified by Stakeholders

The following bulleted list is a loosely structured summary of some of the important comments made by panelists—representatives of the public health, health care (providers and institutions), and first responder communities—invited to address the committee at its November 6, 2003, meeting. CDC has stated that the assessments that will be conducted through the Public Health Preparedness Project will help identify technical assistance needs and gaps in preparedness of state and local public health agencies (Henderson, 2003a). These assessments will be an important tool for gathering information about how preparedness activities across the country need to be improved. To provide some interim guidance, before the systematic assessments of needs and gaps are implemented, the committee summarizes suggestions, problems, and insights offered by panelists. Although these issues are not necessarily incorporated into formal recommendations based on the charge to the committee, CDC is encouraged to consider these issues as appropriate prior to conducting the formal state assessments.

Panelist Comments About Training and Education
  • Fire, police, and Emergency Medical Services (EMS) personnel expressed a desire for a simple pocket card that they could keep in their wallets that would describe the symptoms of smallpox compared to other rash illnesses and whom they should call if they suspect they are responding to a case of smallpox (Fischler, 2003).

  • There needs to be greater coordination with primary care clinicians. Many are untrained in how to diagnose a case of smallpox (or the manifestation of any other bioterror or chemical agent), as well as how to report a suspected case. Education needs include “just-in-time” information available in real-time to physicians and other health care providers in the event of a possible case (Temte, 2003).

  • One way to encourage clinicians to educate themselves on bioterrorism preparedness could be to include some elements of clinical bioterrorism expertise in the regular certification and recertification processes (Hirshon, 2003; Roquemore, 2003).

  • First responder personnel need to receive additional education. Any educational materials provided to first responders and health care personnel must be easily accessible, organized simply, and provide the necessary information succinctly (Dunn, 2003; Fischler, 2003; Temte, 2003).

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
Panelist Comments About Resources (e.g., human, equipment and supplies, communication)
  • Many fire, police, and emergency medical services personnel do not have access to personal protective equipment in the case of a bioterror or chemical attack (Peterson, 2003).

  • 911 centers should be considered important communication nodes in providing information to the public during an emergency (though these, of course, should not be considered the primary communication nodes) (Fischler, 2003; Maniscalco, 2003; Trimble, 2003).

  • A census of emergency medical technicians and EMS agencies, describing how EMS services are organized across the country (and thus, where the connections need to be made for bioterrorism preparedness), has not been conducted since the 1970s (Maniscalco, 2003).

  • Many health care professionals currently are not in active practice. They may be in administration, policy, academia, or other careers. It may be useful to work with related professional associations to determine if any of these nonpracticing health care professionals could be mobilized to serve in a clinical capacity in the event of an outbreak (Ricci, 2003).

  • Lists of vaccinated and trained health care personnel could be updated using health care professional licensure lists (Peterson, 2003).

  • Representatives of both health care and first responder personnel strongly suggested that these personnel and their immediate families receive priority vaccination should a smallpox outbreak occur. For some panelists, this problem could be addressed by increasing access to pre-event vaccination for responders and their families. Health care workers and first responders may be reluctant to report for duty, or be distracted during duty, if they are unsure that their families are protected. Consideration of these issues may be related to supporting surge capacity (Fischler, 2003; Peterson, 2003; Temte, 2003).

Panelist Comments About Surge Capacity
  • Changes in the scope of practice of EMS providers for emergencies should be considered, since the health care training that these personnel have received could, where appropriate, contribute to surge capacity in mass vaccination clinics (Fischler, 2003).

  • The surge capacity needs of public health laboratories also must be considered. A suspected or confirmed outbreak greatly will increase the number of environmental samples that must be tested by public health laboratories (e.g., testing for anthrax at post offices) (Kelley, 2003).

  • Another area of surge capacity that should not be overlooked pertains to handling human remains in an event with significant mortality. The

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

role of DMORTS and whether their services can fulfill all the surge capacity needs in multiple communities are still unclear (Dunn, 2003).

Panelist Comments about Mental Health
  • It is unclear how much federal coordination exists around mental health issues during a smallpox emergency. SAMHSA’s role in a smallpox emergency should be characterized more clearly (Benjamin, 2003; Temte, 2003).

Panelist Comments about Populations with Special Needs
  • Special issues and concerns of the uninsured and undocumented immigrants need to be considered to a greater extent, as well as the needs of those who are homeless or have disabilities (Benjamin, 2003; Peterson, 2003; Temte, 2003).

CONCLUDING REMARKS

The committee commends CDC for responding to the needs of state and local public health agencies by developing smallpox and overall public health readiness indicators. These indicators are an important step in ensuring that states receive clear guidance on how to become more prepared to respond to a public health emergency, understand how they will be held accountable, and are assured of the federal role in national preparedness for a public health emergency. By addressing the three tasks with which CDC asked for advice (reviewing the smallpox readiness indicators, identifying criteria that could be used for the smallpox indicators, and developing smallpox scenarios that could be used to test the smallpox indicators), the committee has attempted to assist CDC with the important work of assessing the nation’s readiness to respond to a smallpox outbreak.

In closing, the committee will summarize the report’s key messages:

  1. Preparedness must include a greater emphasis on planning, management, and decision-making.

  2. Readiness to respond to public health emergencies (including smallpox emergencies) should be part of overall continuous quality improvement of the public health system.

  3. CDC should address its immediate need of measuring cooperative agreement compliance with a concise and simple set of indicators, and then use this set of indicators as the foundation of a longer, deliberative, national process to develop measures that address the full range and appropriate balance of preparedness activities.

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
  1. Federal agencies bear unique responsibilities in emergency response, and they should be held accountable and assessed on their progress, similar to their state and local counterparts.

  2. Public health readiness indicators need to address each of the distinct roles of federal, state, and local jurisdictions in the planning for and response to a public health or, specifically, smallpox emergency.

  3. The current set of readiness indicators provides a useful start to measuring preparedness, but many indicators seem too broad and redundant, and not based on any evident framework, such as one common to the public health system.

  4. The draft readiness indicators do not reflect the significance of active and sustained collaboration and communication among the public health system, the health care system, first responders, and the community (conceived in the broadest sense).

The committee wishes to thank you for the continuing opportunity to be of assistance to the Centers for Disease Control and Prevention and its partners as they work to protect the nation’s health.

Brian L. Strom,

Committee Chair

Kristine M. Gebbie,

Committee Vice Chair

Robert B. Wallace,

Committee Vice Chair

Committee on Smallpox Vaccination Program Implementation

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Austin B. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:9-11, 13.


Benjamin G. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:144.

Blank S, Moskin LC, Zucker JR. 2003. An ounce of prevention is a ton of work: mass antibiotic prophylaxis for anthrax, New York City, 2001. Emerging Infectious Diseases 9(6):615-622.


CDC (Centers for Disease Control and Prevention). 2003a. Unpublished. Information and Instructions on Review of CDC’s Smallpox Readiness Indicators for the Institute of Medicine’s Smallpox Committee.

CDC. 2003b. Local Public Health System Performance Assessment Instrument in National Public Health Performance Standards Program. [Online] Available at http://www.phppo.cdc.gov/nphpsp/Documents/Local_v_1_OMB_0920-0555.pdf. Accessed November 14, 2003.

CDC. 2003c. National Public Health Performance Standards Program. [Online] Available at http://www.phppo.cdc.gov/nphpsp/. Accessed November 14, 2003.

CDC. 2003d. State Public Health System Performance Assessment Instrument in National Public Health Performance Standards Program . [Online] Available at http://www.phppo.cdc.gov/nphpsp/Documents/State_v_1_OMB_0920-0557.pdf. Accessed November 14, 2003.

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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DOJ (U.S. Department of Justice). 2000. Fiscal Year 1999 State Domestic Preparedness Support Program. [Online] Available at http://www.ojp.usdoj.gov/odp/assessment.pdf. Accessed November 14, 2003.

Dunn V. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:195-196, 207, 220.


Edmiston CE, Graham MB, Wilson PJ, Grahn B. 2003. The monkeypox virus outbreak: reflections from the frontline. American Journal of Infection Control 31:382-384.

Emanuel EJ. 2003. The lessons of SARS. Annals of Internal Medicine. 139(7):589-591.


Fischler D. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC: 228-239, 252.


GAO (U.S. General Accounting Office). 2000. West Nile Virus Outbreak: Lessons for Public Health Preparedness. GAO/HEHS-00-180. Washington, DC: Health, Education, and Human Services Division.

GAO. 2003. Infectious Diseases: Gaps Remain in Surveillance Capabilities of State and Local Agencies. GAO-03-1176T. Washington, DC: Health, Education, and Human Services Division.


Henderson J. 2003a. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:26-108.

Henderson J. 2003b. Update on National Smallpox Preparedness: Smallpox Preparedness Indicators. Presented to the IOM’s Committee on Smallpox Vaccination Program Implementation on November 6, 2003.

Hirshon JM. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:180.


IOM (Institute of Medicine). 2001. Tools for Evaluating the Metropolitan Medical Response System Program: Phase I Report. Washington, DC: National Academy Press.

IOM. 2002a. The Future of the Public’s Health in the 21st Century. Washington, DC: The National Academies Press.

IOM. 2002b. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press.

IOM. 2003a. Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation: Letter Report #2. Washington, DC: The National Academies Press.

IOM. 2003b. Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation: Letter Report #4. Washington, DC: The National Academies Press.


Kelley K. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003 in Washington, DC:141-142.


MacKenzie D. 2003, June 21. Slow Response to Monkeypox Reveals Glaring Gap in Bioterror Defenses. New Scientist, 12.

Maniscalco P. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:243-244, 260-261.


NACCHO (National Association of County and City Health Officials). 2002. Compendium of Resolutions. [Online] Available at http://www.naccho.org/files/documents/compendium-May-2002.pdf. Accessed November 14, 2003.

Neustadt RE, Fineberg HF. 1978. The Swine Flu Affair: Decision-Making on a Slippery Disease. U.S. Department of Health, Education, and Welfare.


Peterson C. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:151-157, 166.

Plough A. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:109-151.

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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Ricci K. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:190.

Roquemore J. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC: 241-242.


Salinsky E. 2002. Will the Nation Be ready for the Next Bioterrorism Attack? Mending Gaps in the Public Health Infrastructure. NHPF Issue Brief No. 776. Washington, DC: National Health Policy Forum.

Selecky M. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Three on May 1, 2003, Washington, DC:93-94.

Schulman R. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:213-214.


Temte J. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC: 157-159, 165-166, 173-174, 186.

Trimble M. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC.


White House. 2002. President Delivers Remarks on Smallpox. [Online] Available at http://www.whitehouse.gov/news/releases/2002/12/20021213-7.html. Accessed January 8, 2003.

WHO (World Health Organization). 2003. Unpublished. Strengthening National Health Preparedness and Response for Chemical and Biological Weapons Threats.

Williamson D. 2003. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting Four on November 6, 2003, Washington, DC:109-151.

APPENDIX 5-A DRAFT SMALLPOX INDICATORS AND SUGGESTED CRITERIA

The committee reviewed the draft 10 smallpox indicators included in CDC’s readiness indicators document. The committee’s analysis does not reflect an endorsement of the current indicators as indicative of readiness for smallpox attack. In fact, some of the indicators seem narrow and unclear, whereas others seem to incorporate multiple activities, and it is not evident whether and how they could represent a carefully selected, concise set of the most relevant measures of smallpox preparedness.

The committee outlined four scenarios, discussed the indicators as they would operate in each scenario, and developed some examples of criteria that might help assess a jurisdiction’s work in an area summarized by a given indicator. Unless otherwise noted, the committee believes that the criteria it developed would apply to all scenarios. The committee has also indicated, as appropriate, whether a criterion is applicable to state public health agencies, local public health agencies, or both.

Indicator 1.1.9.1: Legal issues related to smallpox vaccination (e.g., liability, compensation, licensure for administration of vaccine, investigational new drug issues) have been reviewed and addressed.

This indicator should be broadened to more fully reflect the wide range of legal issues pertaining not only to vaccination, but to smallpox prepared-

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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ness in general. Such issues would include quarantine, isolation, access to medical records, legal authority to mandate employees to work, emergency medical technicians’ scope of practice, etc.

Within the framework provided by the Ten Essential Public Health Services, this indicator corresponds to Essential Services 5 and 6.

Suggested Criteria
  • Are appropriate consent forms available and in use? (most relevant for scenario 1, and less for 2-4) (either state or local level, as appropriate)

  • Are copies of relevant public health law available in all appropriate agencies?

  • Is there documentation of thorough legal review to ensure that the jurisdiction’s law is current, including a record of changes and decisions made with policy-makers? (state level)

  • Is information about relevant public health laws included in new employee orientation handbooks? (state and local levels)

  • Is there documentation of legal authority for emergency licensing and credentialing?

  • Are there information sheets describing the relevant legal issues in appropriate language to all relevant stakeholders, including the general public? (state or local, depending on the state’s plan)

  • What evidence is there of a review of federal legislation and decisions made? (most important in scenario 4)

  • Have federal agencies provided state/local agencies with documentation of federal legal authority and described under what circumstances federal agencies would become involved and what they would do (or other material defining the transition from one level of authority to another)? (most important in scenario 4)

Indicator 1.3.3.1: Local and/or state public health has identified and secured governmental and nongovernmental agencies for surge capacity at mass distribution sites for medical countermeasures (e.g., vaccination).

Indicator 1.3.4.1: Local and/or state public health has trained governmental and nongovernmental agencies for surge capacity at mass distribution sites for medical countermeasures (e.g., vaccination).

Indicator 1.3.5.1: Local and/or state public health has identified and secured community resources for surge capacity as mass distribution for medical countermeasures (e.g., facilities).

The three indicators above can be easily grouped into one, because they are all related to preparation for mass distribution of vaccine (or other

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

countermeasures). The new, joint indicator might read as follows: Local and/or state public health has identified, engaged, and trained governmental and nongovernmental agencies to participate in and taken the necessary steps to establish sites for mass distribution of vaccine (or other countermeasures).

Within the framework provided by the Ten Essential Public Health Services, these indicators correspond to Essential Service 7 and 8.

Suggested Criteria
  • Does the agency have lists with contact information, addresses, and letters of agreement with all planned distribution sites in the community? (state or local, depending on which is managing the distribution process)

  • Does the operational plan (which should be consistent with CDC guidelines) include rosters of staff, with contact information, functional role descriptions, and evidence of training for all personnel on the roster? (state or local, depending on which is managing the distribution process)

  • Are there written collaborative agreements with all agencies that would be involved in some aspect of vaccination/distribution of countermeasures (school districts, EMS, law enforcement, etc.)? (state or local, depending on which is managing the distribution process)

Indicator 2.3.1.1: Local and/or state public health maintains core personnel who are trained to provide technical assistance in the differential diagnosis of smallpox syndrome.

Indicator 3.1.10.1: Local and/or state public health trains health care personnel to provide differential diagnosis of smallpox syndrome.

These indicators are closely related and should be integrated. “Differential diagnosis” is more clearly worded as “confirming the diagnosis of….” The new, combined indicator might read as follows: Local and/or state public health agency has trained health care personnel and has core personnel available to provide technical assistance in confirming the diagnosis of smallpox syndrome.

Within the framework provided by the Ten Essential Public Health Services, these indicators correspond to Essential Service 2 and 8.

Suggested Criteria
  • Is there a plan for ongoing education and training of health care providers and evidence of its implementation? (state or local, depending on specific state plan)

  • Do local public health agencies have contact information at every

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

hospital and a communication method for immediately informing all hospital and community-based providers of a smallpox case?

  • Is there a system for 24/7 two-way communication between the public health agency and health care providers (including what samples to get and where to send them)?

  • Does the alert system include information on how a provider can immediately access “just-in-time” provider training on the diagnosis of smallpox?

All these criteria (except the first) would be evidenced by retrospective analysis of actual test cases (monkeypox, varicella) or a (unannounced) test case/drill.

Indicator 3.1.12.1: Local and/or state public health has secured community resources for surge capacity as sites for medical care and monitoring for potential victims of a smallpox outbreak (e.g. facilities).

Within the framework provided by the Ten Essential Public Health Services, this indicator corresponds to Essential Services 4 and 7.

Suggested Criteria
  • Is there a community plan for the distribution of initial smallpox cases for medical care?

  • Is there a triage plan for making space for an escalating number of cases?

  • Are there resources (workforce, buildings, access to emergency funds) or plans to access resources to operationalize the triage plan?

  • e.g., is there a current contact list for health care providers who have agreed to participate in the treatment of victims, including their vaccination status and multiple means to contact them?

  • e.g., is there a list of all appropriate isolation rooms in the community?

  • Is there a plan for the disposal of remains?

  • Do facility/agency plans identify the other services or functions that would need to be maintained during the emergency (what must be provided and what can temporarily be suspended)?

  • Are plans in place to support the environmental sampling surge capacity needs of public health laboratories?

  • Is there a plan for the psychological management and general mental health issues of the worried well and of the families of health care providers and first responders?

  • Is there a plan for the recovery of facilities after the epidemic is ended?

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

Indicator 3.1.3.1: Local and/or state public health identified members of epidemiology investigation and surveillance teams targeted for immediate smallpox vaccination.

This indicator is unclear in several ways. First, it should be clarified whether “immediate” means “pre-event,” and whether “epidemiology investigation and surveillance teams” refers to the public health response teams commonly described in the CDC guidance. Second, the wording used implies three related tasks: the identification of teams, defining the qualifications required for teams, and the vaccination of teams. It should be made clear exactly which task(s) the indicator aims to evaluate. Because this indicator only applies to pre-event activities, it is only applicable to scenario 1; it is presumed under scenarios 2, 3, and 4.

Within the framework provided by the Ten Essential Public Health Services, this indicator corresponds to Essential Services 1 and 2.

Suggested Criteria
  • Is there an updated list or registry for each locale with smallpox public health response team members’ names, contact information, and vaccination status?

  • Does the team possess the minimum public health bioterrorism response competencies appropriate to their role(s)?

  • Is there an effective, efficient notification system for contacting team members?

Indicator 3.1.9.1: Local and/or state public health identifies members of epidemiology and investigation teams targeted for immediate smallpox vaccination following the notification of an outbreak.

The indicator wording should be clarified to explain what “notification of an outbreak” really means. Does this mean when an outbreak is officially declared? Immediately after a single case is identified? When an outbreak occurs anywhere in the world or in the United States? Also, as in 3.1.3.1, does “epidemiology investigation and surveillance teams” mean the public health response teams commonly described in the CDC guidance?

The indicator also implies three different tasks, and it is unclear which task is being evaluated, whether it is the identification of teams, the vaccination of teams, or the expansion of teams with functional role descriptions for needed expertise.

This indicator is not applicable to scenario 1, which is pre-event (i.e., before an outbreak), but it may apply to scenario 2 and is most relevant to scenarios 3 and 4 due to enhanced surveillance needs.

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

Within the framework provided by the Ten Essential Public Health Services, this indicator corresponds to Essential Services 1 and 2.

Suggested Criteria
  • Is there an updated list/registry for each locale with smallpox emergency team members’ names, contact information, and vaccination status?

  • Does the team possess the minimum team competencies as described above? If not, is there a plan for acquiring members with those competencies immediately after notification of an outbreak?

  • Has the notification system for contacting team members been tested and is it effective in mobilizing the team within the desired time frame (with a time parameter if that can be identified)?

Indicator 3.3.2.1: Local and/or state public health will stockpile at least 20 doses of smallpox vaccine per 100,000 population to be available at all times (or a minimum of 1,000 doses [=10 vials] for states with population <3 million) in order to respond initially to a smallpox outbreak using search and containment strategies.

It seems that the terms “search and containment” imply that this stockpile is meant for commencing ring vaccination and intended to be short-term and limited. It is unclear whether states are advised to have one or multiple storage sites. Furthermore, is there a plan (and ways to communicate it) for prioritizing access to the vaccine in the initial 24 hours postevent, including considering vaccinating the families of responders?

This indicator applies to all scenarios.

Within the framework provided by the Ten Essential Public Health Services, this indicator corresponds to Essential Service 7.

Suggested Criteria
  • Is the stockpiled smallpox vaccine in an appropriate storage facility (“appropriate” to be defined by CDC)?

  • Is there a distribution plan for the stockpile, with a timeline for distribution?

Possible Additional Indicators

The set of smallpox indicators, as well as that of overall readiness indicators, seems to lack several important measures. Some, such as measures to assess communication and collaboration, were discussed to a greater extend in the text of the report. As CDC moves forward in refining and

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

pilot-testing the indicators, some additional areas should be considered to ensure that even a limited set of indicators provides a comprehensive assessment of readiness. Such additional measures include, but are not limited to:

  • Sentinel indicators of diversion of effort, such as childhood immunization rates.

  • The implementation of exercises and drills (which are both a way to test some of the criteria for various indicators, and an indicator on their own—does public health agency conduct drills/exercises and how does it do?).

APPENDIX 5-B SUMMARY OF RECOMMENDATIONS

  1. If CDC intends to use scenarios as a planning tool, the committee recommends that the scenarios represent a range of possible situations, be used to help guide state and local planning activities, and facilitate state and local assessment of their level of preparedness.

  2. The committee recommends that a flexible, incremental, science-based decision-making and management structure for smallpox response that includes all levels of government be developed and communicated to state and local agencies so that the consequences of a smallpox outbreak can be managed effectively.

  3. The committee recommends that CDC consider conducting the preparedness assessments on a multiyear basis.

  4. The committee recommends that CDC address its immediate need of measuring cooperative agreement compliance with a concise and simple set of indicators, and then use this set of indicators as the foundation of a longer, deliberative, national process to develop measures that address the full range and appropriate balance of preparedness activities.

  5. The committee recommends that federal agencies and CDC, specifically, be held accountable for their unique federal responsibilities in an emergency response and assessed on their progress in facilitating national public health emergency preparedness.

  6. The committee recommends that CDC consider utilizing the Ten Essential Public Health Services as a framework for the readiness indicators.

  7. The committee recommends that CDC collaborate with HRSA to integrate the preparedness indicators into one document, in order to help the health care and public health communities work hand-in-hand to plan, implement plans, and evaluate their readiness to respond to threats (includ-

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×

ing, but not limited to, a smallpox attack) and to avoid requiring duplicate reporting from states.

APPENDIX 5-C ESSENTIAL CAPABILITIES NEEDED FOR PREPAREDNESS

Source: IOM. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press, pp. 115-159.

  1. Relationship development

  2. Communication system development

  3. Hazard assessment

  4. Training

  5. Equipment and supplies

  6. Mass immunization and prophylaxis

  7. Addressing the information needs of the public and the news media

  8. First responder protection

  9. Rescue and stabilization of victims

  10. Diagnosis and agent identification

  11. Decontamination of victims

  12. Transportation of victims

  13. Distribution of supplies, equipment, and pharmaceuticals

  14. Shelter and feeding of evacuated and displaced persons

  15. Definitive medical care (includes mass immunization or distribution of drugs or vaccines)

  16. Mental health services for responders, victims, caregivers, and their families

  17. Volunteer utilization and control

  18. Crowd and traffic control

  19. Evacuation and quarantine decisions and operations

  20. Fatality management

  21. Environmental cleanup, physical restoration of facilities, and certification of safety

  22. Follow-up study of responder, caregiver, and victim health

  23. Process for continuous evaluation of needs and resources

Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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×
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×
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×
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×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
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×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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Suggested Citation:"Appendix F: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #5." Institute of Medicine. 2005. The Smallpox Vaccination Program: Public Health in an Age of Terrorism. Washington, DC: The National Academies Press. doi: 10.17226/11240.
×
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×
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×
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×
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×
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×
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December 13, 2002, the president of the United States announced that smallpox vaccination would be offered to some categories of civilians and administered to members of the military and government representatives in high-risk areas of the world. The events that precipitated that historic announcement included a series of terrorist attacks during the 1990s, which culminated in the catastrophic events of 2001.

Although preparedness for deliberate attacks with biologic weapons was already the subject of much public health planning, meetings, and publications as the twentieth century neared its end, the events of 2001 led to a steep rise in bioterrorism-related government policies and funding, and in state and local preparedness activities, for example, in public health, health care, and the emergency response and public safety communities. The national smallpox vaccination program is but one of many efforts to improve readiness to respond to deliberate releases of biologic agents.

The Institute of Medicine (IOM) Committee on Smallpox Vaccination Program Implementation was convened in October 2002 at the request of the Centers for Disease Control and Prevention (CDC), the federal agency charged with implementing the government's policy of providing smallpox vaccine first to public health and health care workers on response teams, then to all interested health care workers and other first responders, and finally to members of the general public who might insist on receiving the vaccine. The committee was charged with providing "advice to the CDC and the program investigators on selected aspects of the smallpox program implementation and evaluation."

The committee met six times over 19 months and wrote a series of brief "letter" reports. The Smallpox Vaccination Program: Public Health in an Age of Terrorism constitutes the committee's seventh and final report, and the committee hopes that it will fulfill three purposes: 1) To serve as an archival document that brings together the six reports addressed to Julie Gerberding, director of CDC, and previously released on line and as short, unbound papers; 2) To serve as a historical document that summarizes milestones in the smallpox vaccination program, and ; 3) To comment on the achievement of overall goals of the smallpox vaccination program (in accordance with the last item in the charge), including lessons learned from the program.

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