little time to identify and resolve potential difficulties (such as the lack of a compensation plan) or to plan carefully for crucial program components, including materials for prospective vaccinees and the data system. Although rapid implementation would be justified in a crisis, the public and program participants were repeatedly assured that there was no evidence of imminent attack with smallpox virus. Chapter 3 also includes a discussion of favorable outcomes and concludes with a detailed chronology, from events that paved the way for the program through the time of this writing. In this chapter, the committee cites mass media references that document the perspective of key constituencies and their perceptions of the program and the federal government’s role. Although media sources are limited in some ways, they provide important insight into the implementation of the program, and the committee has found them concordant with information gathered during the committee’s public meetings.

The report’s fourth and final chapter, “Lessons Learned from the Smallpox Vaccination Program,” constitutes the core of the report, and in that chapter the committee discusses two additional sets of findings from its review of the program and provides a conclusion and a recommendation based on the findings (see Figure ES-1). Trust is a unifying theme among the committee’s findings. The committee asserts that a relationship of trust between CDC and the public health and health care communities is a critical requirement in the implementation of biopreparedness programs.

The committee recognized that CDC requested IOM’s guidance on the implementation of the program, not on the smallpox vaccination policy itself. Therefore, in its deliberations the committee made every effort to separate the program from the policy-making that preceded it. In Chapter 4, the committee continues its work within the boundaries of the charge by not commenting on the substance of the policy itself. However, the committee’s interpretation of its charge is broadened somewhat, allowing it to examine the way the policy and its rationale were communicated and the effects that appeared to have had on the implementation of the program and on the achievement of overall goals of the program (as stated in the last item of the charge).

The smallpox vaccination program involved the implementation of a public health strategy that required the buy-in and participation of numerous public health and health care administrators and personnel. It is a well-documented principle of health promotion planning that the commitment and attitudes of staff who will implement a program are critical to its success, and that they are shaped in the process of communication and information-sharing (Green and Kreuter, 1991). Also, public health practitioners have long known that the activities of community health improvement require “buy-in from those who control what is to be changed” (Nolan, 2004). Smallpox vaccination has been implemented as a public

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