of vaccinees by stating that even as few as 50,000 vaccinated people could mount an effective response (GAO, 2003). However, that number was not formally announced as the new target figure for the national pre-event vaccination program, and the report stated that CDC did not provide the evidence for the smaller number, nor did it outline what level of vaccination was necessary for smallpox preparedness (GAO, 2003; McGlinchey, 2003a).

As the smallpox vaccination program moved away from an emphasis on numbers to an emphasis on smallpox preparedness, public health agencies at the state and local levels reported that they lacked guidance about what preparedness meant and about how to assess whether they were prepared for a potential smallpox release (GAO, 2003; Selecky, 2003). The lack of clarity about program goals identified above remained a problem. The GAO report recommended that CDC provide guidance to its grantees for revising phase I vaccination targets and for expanding the program in the second phase.

Supplementary Funding for the Smallpox Vaccination Program

On May 5, 2003, DHHS notified the states that $100 million in supplemental funding would be made available to support smallpox vaccination efforts. The additional funding aimed to address state and local public health agency concerns about the costs imposed by the program. Although the overall effect of the funding has not been assessed, one local health official testified before a U.S. House of Representatives committee that the supplemental funding came too late for her public health agency, which had “cut other commitments” to implement the smallpox vaccination program (U.S. House of Representatives, 2004).

The timing of the smallpox vaccination program coincided with a period of intense budgetary crises in most state governments (NGA, 2003). Soon after the beginning of the program, ASTHO, the National Association of County and City Health Officials (NACCHO), and various state and local health officials, some of whom considered the program an unfunded mandate, provided program cost estimates that far exceeded CDC’s estimate (Colacecchi and Jones, 2003; Libbey, 2003; Rosado, 2003). CDC’s testimony before the Senate Committee on Health, Education, Labor, and Pensions on January 30, 2003, gave an estimated cost of vaccination of $10-15 per person, compared with the estimates of NACCHO and state and local health officials, which ranged from $100 to $400 per vaccinee (Colacecchi and Jones, 2003; Libbey, 2003). Although vaccination kits

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