war Intelligence Assessments on Iraq (assuming that this evidence was used to make smallpox vaccination policy), which found the evidence of the presence of smallpox virus in Iraq to be weak (U.S. Senate Select Committee on Intelligence, 2004).

The rationale for the vaccination program was not formally linked with the possible and later impending war with Iraq, a nation suspected of possessing weapons of mass destruction (perhaps including smallpox virus, on the basis of information from the 1990s). However, the public comments of three public health officials (CDC Director Julie Gerberding, DHHS Secretary Tommy Thompson, and National Immunization Program Director Walter Orenstein) and two legislators (Senators Judd Gregg and Bill Frist) alluded to the war in a way that could be construed as suggestive of a link or suggested that the war served as an impetus for the increased number of vaccinees and rapid program implementation (Connolly, 2003a; Hallow, 2002; Manning and Sternberg, 2002; Rath and Turcotte, 2003; Reuters, 2003). Multiple mass media reports indicate that some public health and health care workers believed that the vaccination program was linked with the war, and public opinion about the vaccination program was split, not unlike public opinion about the war (Russell, 2003). Evidence from the mass media and from an ASTHO survey suggests that the perceived association between the war and the vaccination program was one of several reasons for suspicion and concern among prospective vaccinees, as well as a barrier to vaccination (ASTHO, 2003). Although government officials neither updated nor reiterated the smallpox threat assessment, mass media reports showed a downward shift in public perception about the level of risk of smallpox release and therefore a decreased motivation to receive the vaccine (Fiorill, 2003; Manning, 2003; McKenna, 2003; Yee, 2003). That shift in public perception may have contributed to the decline in the vaccination rate in April and May 2003.

The Compensation Plan

In April 2003, a compensation plan for people who experienced a smallpox vaccine injury was signed into law, largely addressing concerns about the adequacy of provisions available to protect people injured by smallpox vaccination and resolving some concerns about institutional liability in the event of inadvertent transmission of vaccinia.

Early in the implementation of the program, health care and public health organizations and labor unions expressed concern about the lack of adequate provisions for vaccine injury compensation and for some types of



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