at IOM committee meetings, and, to a lesser extent, mass media reports (when multiple reports corroborating an event were available). During the development of the smallpox vaccination policy, there was communication among CDC, DHHS, the Office (later the Department) of Homeland Security, and the White House (Cohen and Enserink, 2002). Multiple constituencies (including various entities in the health care, public health, and first responder communities) provided written and oral input to CDC and to Congress (for example, at CDC-organized forums across the nation) in the months before the policy was developed and during its implementation. For example, during summer 2002, CDC engaged its state and local partners (such as representatives of ASTHO and the Council of State and Territorial Epidemiologists) in numerous discussions and provided multiple opportunities for comment about the policy options being considered (ASTHO, 2002; CDC, 2002a; IOM, 2002). In June 2002, ASTHO held a conference call and then conducted a survey to determine its members’ views on strategies for smallpox preparedness. The survey found that a majority of state health officials were opposed to pre-event vaccination of the general public, but most supported pre-event vaccination of designated response teams (Banks and Hannan, 2002). Consensus reached at the June 2002 ACIP meeting reflected a similar opposition to pre-event vaccination of the general public and support for vaccination of specific groups of responders (CDC, 2002b). The ultimate policy decision on vaccinating members of the general public and on vaccinating health care workers differed from the consensus of key constituencies, and it is unclear to what extent their expertise and input were considered.

The collaborative nature of public health in the United States, described in the IOM report The Future of the Public’s Health in the 21st Century, makes partnership and communication essential to any program’s success. Within that process, the credibility of information and decisions from the national level sets the stage for all later decisions and actions by state and local health departments and their partners. Not knowing what evidence was considered and not receiving information about it from CDC—as evidenced by the fact that key partners, such as ASTHO, requested clarification (to the committee’s knowledge never provided) of the rationale behind the policy and the structure of the program—may have affected the public health community’s trust in CDC, as is evident in the expressed perceptions and concerns of many in the public health and health care communities (ASTHO, 2003; Pendley, 2003; Markowitz and Rosner, 2004). A recent CDC analysis of the swine influenza vaccination program of 1976 noted the importance of ensuring the credibility of decisions made by CDC (DHHS, 2004). The Neustadt and Fineberg analysis (1983) of the swine flu program also concluded that the program demonstrated an “insensitivity to the long-term credibility of institutions.”



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