The program did not begin immediately after the president’s announcement, because government coverage of liability (of vaccine manufacturers, hospitals, and health departments that would operate vaccination clinics) in the provision of bioterrorism countermeasures (vaccine) would not go into effect until weeks later. On January 22, 2003, CDC began shipping smallpox vaccine from its vaccine stockpiles to the 11 states that had requested it. On January 24, 2003, the secretary of Health and Human Services declared that the smallpox vaccination program could begin under the authority of an amendment to the Public Health Service Act by Section 304 of the Homeland Security Act3 (DHHS, 2003a). The secretary’s declaration marked the true beginning of the smallpox vaccination program, in that states, territories, and municipalities chose to defer program implementation until the protections conferred by the Homeland Security Act went into effect (Kemper, 2003a).
Vaccination programs in the 62 states, territories, and municipalities began gradually. Some jurisdictions ordered vaccine stocks as soon as CDC made them available and began vaccinating immediately after the program was authorized. Other jurisdictions delayed ordering vaccine and initiating vaccination in order to finalize their plans, or in expectation of CDC’s completion of program components (such as the safety system and informational materials), or to await the settlement of the unresolved vaccine injury compensation issue for people injured by the vaccine or the accidental, inadvertent transmission of vaccinia from a vaccination site.
The vaccination program was generally supported by the public health and health care communities in recognition of the need for biopreparedness (ANA, 2002; Hardy, 2002; Libbey 2003). A survey of state health officials in June 2002 found that a majority (77 percent of 44 respondents) favored smallpox vaccination of designated response teams (Banks and Hannan, 2002). Two surveys of physicians, nurses, and other health care personnel largely working in emergency departments, conducted in late 2002, found that that a majority of respondents (61 percent of 1,165 respondents in one survey, 73 percent of 1,701 respondents in the other) expressed a willingness to receive smallpox vaccination as part of a pre-event program (Everett et al., 2002; Yih et al., 2003). However, support of the program by the public health and health care communities was qualified because of questions and concerns about several aspects of the program; these contributed