public health agencies and first responders (Anderson, 2003; Bresnitz, 2003; Fischler, 2003; Nikolai, 2003; Toomey, 2003).

The smallpox vaccination program provided coincidental preparation for the monkeypox event. A great deal of training about smallpox and, to a lesser extent, orthopoxviruses was implemented, and the health care community was more prepared to identify unusual rashes and probably more attuned to any symptoms out of the ordinary. That meant that when monkeypox appeared in the United States, there was a greater awareness and even readiness among health care providers. Because of the smallpox vaccination program, vaccine was readily available in all the states that had monkeypox cases, and trained and experienced personnel were available to screen, vaccinate, and follow up (Yee, 2003).

The smallpox vaccination program is also reported to have had a favorable effect on the state and local public health response to SARS, which emerged late in 2002 and continued through spring 2003 (Staiti et al., 2003). Although there is little empirical evidence to pinpoint or quantify improved performance, public health agencies have reported improved communication with their health care counterparts and an improved surveillance system (Judson, 2003; Selecky, 2003; Skivington, 2003; Witt, 2003).

Finally, the vaccination program provided opportunities to learn more about adverse vaccine effects in adults. Adverse events surveillance during implementation led to the identification of a new serious adverse event. Cases of myo/pericarditis were confirmed in the military program, and probable cases were identified in the civilian program, necessitating followup and future study.

The vaccination program served as a case study of biopreparedness with relevance for future similar endeavors. The committee has previously urged CDC to take full advantage of the data collected and experience gained in the course of implementing the program (IOM, 2003b, 2003d). Evaluation and research activities could be undertaken in areas ranging from the administrative to the scientific, from determining the overall cost of the smallpox vaccination program and specific components to assessing the opportunity cost to public health agencies and identifying long-term effects of vaccine-related adverse events.

CONCLUDING OBSERVATIONS

Implementation of the smallpox vaccination program began in January 2003 and is continuing. The rate of vaccination rose gradually for the first several weeks but then began a steep decline from which it never recovered—monthly vaccination numbers dropped to the single digits during summer 2004.



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