willingness to be vaccinated if they were designated as members of smallpox response teams (Banks and Hannan, 2002; Everett et al., 2002; IOM, 2002; Yih et al., 2003). Yet the high degree of support for limited smallpox vaccination to prepare the nation to respond to attack did not generate a substantial turnout of volunteer vaccinees; by the end of 2004, fewer than 40,000 people had been vaccinated, far short of original estimates of turnout. The committee found several possible and related reasons for that incongruity.

First, the scientific and public health rationale that led to the smallpox vaccination policy was never fully explained to key constituencies—traditional partners in the development and implementation of public health strategies, including state and local public health agencies—that provided input to the process but whose advice and perspectives were not reflected in the final policy. Although the committee recognizes that the terrorist attacks of 2001 were a dramatic and persuasive reminder of the importance of biopreparedness, it was never made clear to the public health and health care communities why smallpox was selected as a primary target for biopreparedness, how pre-event smallpox vaccination was identified as a core strategy, and why vaccination was urgent.

Second, the scientific and public health rationale that led to the structure of the smallpox vaccination program (in its final form, characterized by the phases and numbers discussed elsewhere in this report) was never fully explained. The ultimate policy called for a much higher number of vaccinees than the original, cautious estimate provided to the government by the Advisory Committee on Immunization Practices (ACIP), and the rationale for offering the vaccine to 500,000 initially, then to up to 10 million, and finally to insistent members of the public was not made clear to important constituencies. Instead, confusing and contradictory information was presented to the public and the public health community about the policy and program.

Third, the limited amount of information that was provided to explain the rationale for the policy and for the structure of the program was neither updated nor reiterated during the course of the program despite strong signals that updating or reiteration was needed.

Fourth, program implementation was characterized by a lack of review of the program’s course and reassessment of starting assumptions. Despite calls for a pause to assess program progress and safety, the program continued. As its pace waned, there was no apparent attempt to reassess or review program implementation and its trajectory.

Finally, and most centrally, the ability of the Centers for Disease Control and Prevention (CDC) to speak authoritatively as the nation’s public health leader, on the basis of the best available scientific reasoning, was severely constrained, presumably by the top levels of the executive branch.

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