to the states called for implementing vaccination within 30 days (CDC, 2002d). After the program began, representatives of the public health community remarked on the challenging timeline and called for slower implementation (Hardy, 2002; Libbey, 2003a, 2003b). Although the initial 30-day timeline was later changed and CDC acknowledged that flexibility would be needed because of administrative difficulties and variation among states, CDC continued to call for rapid implementation without specifying the reason (CDC, 2003a, 2003c; Ornstein and Bonilla, 2003; Russell, 2003). CDC’s emphasis on safety and speed seemed contradictory and generated confusion and an atmosphere of near-crisis in which public health agencies at all levels felt compelled to undertake smallpox vaccination activities about which they had doubts (ASTHO, 2003; Connolly, 2003b; Cook, 2003; McKenna, 2003; NACCHO, 2003a; Pezzino, 2003). In addition, owing to the remarkable speed with which the program was implemented, a number of administrative and procedural components were not ready for implementation, as discussed in greater detail in Chapter 3. Although impending crisis would have justified a rapid response, that was not the case that was made. Instead, the rush to vaccinate as many personnel as possible as rapidly as possible gave rise to concerns about the wisdom of exposing people to an unsafe vaccine in the absence of a known threat of disease.

As described in Chapter 3, the present IOM committee and ASTHO urged CDC to pause after the first phase of vaccination to assess program safety and to plan for the next phase, and ACIP recommended terminating the program because of the occurrence of cardiac adverse events and their unknown long-term safety ramifications (CDC, 2003d; IOM, 2003d; Meckler, 2003a). The present committee repeated its call for a pause in the vaccination program in another report in which that was the primary recommendation (IOM, 2003b); however, despite its acknowledgment of the importance of safety, CDC stated that it expected the program to progress seamlessly from one phase to the next, at least in part to maintain momentum (Henderson, 2003; McGlinchey, 2003a). It is not clear whether CDC discussed the merits and costs of a pause in the vaccination program with its state and local counterparts. In the end, multiple state and local programs paused or stalled simply for lack of volunteer vaccinees.

The juxtaposition of impending war with the uncertainty surrounding the rationale for the vaccination policy and the lack of information pertaining to the smallpox threat assessment may have contributed to the program’s slow progress. In January and February 2003, simultaneously with the implementation of smallpox vaccination, the administration was demonstrating to the nation and international allies that a war in Iraq was neces-