behind the smallpox vaccination policy and program was never fully explained. Skepticism among key constituencies was followed by a lack of buy-in. Despite their expressed willingness to strengthen preparedness for bioterrorism in general, and their desire to serve their communities, many public health and health care workers were ultimately unwilling to accept the well-known risks of smallpox vaccine in the context of limited information about the risk of smallpox. The lack of buy-in led to poor participation in the vaccination program.

In addition to the fact that the rationale for the program and its structure was not explained, communication with key constituencies created confusion and concern. The typically open and transparent communication from CDC—the nation’s public health leader that generally provides guidance for science-based decision-making—seemed constrained by unknown external influences. Furthermore, as the program was experiencing difficulties and appeared to fall short of initial expectations, goals were not clarified or revised in any substantial way. For example, if it was important to vaccinate specific numbers rapidly, what was the effect of the low vaccinee numbers on readiness for a release of smallpox virus? This question went unanswered, as did the larger questions about the definition and requirements of smallpox preparedness.

Based on the lessons learned from the smallpox vaccination program, the committee concludes that a policy strategy and a mechanism are needed to balance the need for scientific evidence and public health analysis with the imperatives of national security, ensuring in the process that the authoritative voice of CDC, the nation’s public health leader, will be preserved.

Finally, the committee found that the program’s outcomes (for example, the status of smallpox preparedness in each jurisdiction and nationally) are unknown because there has been no systematic assessment of smallpox preparedness, no review of administrative lessons learned, and no accounting of what has been done with the opportunities for scientific research. At the time of this writing, the status of efforts to develop measures and indicators for smallpox (and bioterrorism) preparedness is unknown.

The committee recommends that, in collaboration with its state and local partners and in the context of broad bioterrorism preparedness, CDC define smallpox preparedness; set goals that reflect the best available scientific and public health reasoning; conduct regular, comprehensive assessments of preparedness at the national level and by state; and communicate to the public about the status of preparedness efforts.

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