structure (Redhead et al., 2002). In the wake of the terror attacks of 2001, the DHHS budget for bioterrorism preparedness increased from $305 million for FY 2001 to $2.98 billion for FY 2002 (DHHS, 2002b).

In 2002, Congress appropriated $940 million to CDC, which made $918 million available to 62 state, territorial, and local public health agencies as part of its Cooperative Agreement on Public Health Preparedness and Response (DHHS, 2002a). Twenty percent of the award was available for immediate use, and 80 percent was contingent on approval of plans submitted to CDC. In FY 2003, funding for CDC’s cooperative agreement was $870 million; in FY 2004, funding had decreased to $849 million (DHHS, 2003a, 2003b). Proposed funding for FY 2005 is $829 million (ASTHO, 2004).

The smallpox vaccination program began as an agent-specific effort somewhat linked with other bioterrorism preparedness activities. When the smallpox vaccination program was announced, there was no specific funding linked with it; the November 2002 planning guidelines provided by CDC stated that the vaccination program would be funded by the already disbursed bioterrorism funds provided to grantees under the CDC cooperative agreement. After state and local public health agencies began to express concerns about the costs of the smallpox vaccination program and about their having to absorb a substantial proportion of funding earmarked for more general bioterrorism preparedness, in addition to other resources, the federal government provided $100 million in one-time supplemental funding for smallpox-related activities (DHHS, 2003b).

CONCLUDING OBSERVATIONS

The federal government’s decision to reintroduce smallpox vaccination was unprecedented and emerged at the challenging intersection of public health with national security considerations related to potential terrorism. A public health immunization program against a nonexistent disease was an unusual step initiated in the context of concern about the possible existence and whereabouts of illegal smallpox virus stocks and the recent bioterrorist attacks on U.S. soil. The smallpox vaccination policy emerged at the intersection of public health with national security considerations related to potential terrorism.

ACIP has long served as a key advisory body to the federal government in all vaccination policy, and ACIP filled this role as it provided recommendations regarding specific aspects of the smallpox vaccination program. Little information has been made public about the other advisory groups and individuals most intimately involved in fashioning the actual policy. However, information available in the news media and in government communications shows that multiple opinions were considered at various



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