figure seemed oddly coincidental with the estimate first suggested by White House officials, and there was some initial concern that ACIP was pressured to modify its earlier recommendation (Brown, 2002; Cohen and Enserink, 2002) (see also discussion in Chapter 2).

The rationale for the second and third phases of the program, vaccinating 10 million responders and insistent members of the general public, respectively, which surpassed and even diverged from ACIP recommendations and from the advice of constituencies such as the American Public Health Association, the American Academy of Family Physicians, the Emergency Nurses Association, and others that called for limited vaccination (AAFP, 2002; APHA, 2002; ENA, 2002; IDSA, 2002; May et al., 2003), was never shared with those who would implement the program or who would volunteer to be vaccinated. There was no apparent public health reasoning behind the decision to offer vaccine to the public. In fact, the present committee stated in its fourth report to CDC that “offering vaccination to members of the general public is contrary to the basic precepts of public health ethics, which focus on a fair and reasonable balance of risks and benefits among individuals and for the population as a whole” (IOM, 2003b; see Appendix E). The nation’s public health and health care communities expected an explanation of the public health reasoning behind the policy that would include an epidemiologic justification for offering vaccination to the three types of vaccinees identified, evidence that vaccinating response teams before a smallpox virus release would ensure a better and faster response to an attack, evidence that vaccinating other types of responders (such as firefighters and police) would substantially improve response effectiveness, and evidence that implementing specific pre-event vaccination activities would be an optimal use of resources as part of bioterrorism preparedness efforts. The committee is unaware of evidence showing whether and how the advantages and disadvantages of various pre-event vaccination options were carefully weighed and compared or evidence that decisions were made accordingly.

Confusing and Contradictory Information About the Policy and the Program

The contradictory and confusing information provided during the implementation of the smallpox vaccination program may have constituted another barrier to implementation of the program and may have undermined CDC’s credibility further. For example, the announcement of the policy and later explanations assured Americans that there was no imminent risk of smallpox virus release (U.S. Department of State, 2002; White House, 2002). Nevertheless, the federal government repeatedly called for rapid implementation of the vaccination program. CDC’s initial guidance

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