government’s intention to vaccinate 500,000, seemed oddly coincidental to observers concerned about undue pressure on the federal advisory panel (Cohen and Enserink, 2002). However, ACIP Chairperson John Modlin and members of ACIP explained that the first, smaller number was based on the assumption that only staff at designated “smallpox hospitals” would be vaccinated (in addition to public health response teams). Later discussion with various stakeholders indicated that hospitals would resist a “smallpox” designation, and at a more practical level, smallpox victims would be more likely to go to the nearest emergency department rather than to a specific hospital (Brown, 2002b; Cohen and Enserink, 2002; Kemper, 2002; Maguire, 2003; Manning and Sternberg, 2002). ACIP had therefore changed its basic assumptions and expanded the number of prospective vaccinees to account for the participation of more hospitals. However, ACIP did not endorse any vaccination beyond the 500,000 response team members and was explicit in its opposition to offering vaccine to the general public, given the vaccine-related risks and the smallpox threat assessment at that time (Brown, 2002b, 2002c; Maguire, 2003).
With the exception of phase I (vaccination of 500,000 volunteers), the federal government’s final policy decision was an unprecedented departure from the ACIP recommendations (Altman, 2002a). As announced by the president on December 13, 2002, and further elaborated in DHHS and CDC communications and telebriefings, the policy called for resuming military vaccinations and in the civilian sector first vaccinating smallpox response team members (a target of about 500,000 was provided by DHHS officials after the president’s announcement). This would be followed by an even larger number of health care and emergency personnel (up to 10 million), and finally, members of the general public who insisted on receiving the vaccine would be vaccinated (although with the caution that the government does not recommend smallpox vaccination for the general public, and with the caveat that the public would be given a new smallpox vaccine not yet developed at the time) (CDC, 2002g; White House, 2002).
In 1999, DHHS launched a bioterrorism initiative that had six goals: preventing bioterorrism, strengthening infectious disease surveillance, enhancing medical and public health readiness for mass casualty events, the National Pharmaceutical Stockpile (renamed the Strategic National Stockpile on March 1, 2003), conducting research on and development of new drugs and vaccines, and strengthening the information technology infra-