a tuberculosis outbreak, its efforts were complicated by the fact that its resources were greatly strained by a combination of budget cuts and the demands of the smallpox vaccination program. Other local health departments reported diverting staff from their regular activities, delays in childhood immunizations, cancelled family planning clinics, cuts in tobacco control and maternal and child health services, and other changes or cuts in services routinely provided by public health agencies (Connolly, 2003b; Cook, 2003; Hughes, 2003; Staiti et al., 2003).

Planning for the smallpox vaccination program appears not to have included sufficient analysis of the potential effect of vaccination activities on the provision of essential public health services and on other preparedness efforts or analysis of the added costs of implementing such a large vaccination program (GAO, 2003; IOM, 2003b, 2003c). It remains unclear to what extent the supplementary funding provided by DHHS in May 2003 ameliorated the fiscal challenges experienced by some jurisdictions.

Lack of Scientific and Public Health Rationale for the Structure of the Vaccination Program

The rationale for the program’s structure also was not fully explained. As discussed in Chapter 3, ACIP’s June 2002 recommendation to CDC and DHHS called for the vaccination of up to 20,000 people: public health personnel who would serve on smallpox public health investigation teams and health care personnel staffing designated “smallpox hospitals” (CDC, 2002b). John Modlin, ACIP chair, acknowledged the group’s unease with the unknown risk of smallpox virus release, but he believed that its recommendation to DHHS and CDC was made carefully. “The committee has been told that the risk is low but not zero. We obviously can’t put a number on that but we … assume that it’s low, and I think the decision that we made … balanced that low or very low risk with … the known risk from the vaccine” (CDC, 2002c). In October 2002, after the mass media had reported on the various figures being considered by the administration, one of which was 500,000 vaccinees, ACIP revised its recommendation in recognition that hospitals would probably resist being designated as smallpox hospitals and, more important, that smallpox-stricken persons would go to the nearest emergency department rather than to a designated location (Altman, 2002; Brown, 2002; CDC, 2002b; Cohen and Enserink, 2002). ACIP’s revised vaccination target was 500,000. The ACIP chair acknowledged that that was a “back-of-the-envelope” calculation based on the assumption that if the nation’s roughly 5,100 acute-care hospitals each vaccinated roughly 100 people, the total would be about a half-million vaccinated health care workers. That may explain in part how the target for the first phase of the program was derived, although to some the 500,000

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