equipment, staff, and other resources to mount an effective response to an attack that uses smallpox virus. Smallpox preparedness also has broader implications for other types of preparedness. For example, the capacity to implement mass vaccination requires many of the plans and resources that are needed to implement mass distribution of other types of countermeasures, from iodine tablets to anthrax prophylaxis.

At the committee’s November 2003 meeting, the director of CDC’s Office of Terrorism Preparedness and Emergency Response (OTPER), Joseph Henderson, presented the agency’s efforts to define and measure public health preparedness, including smallpox preparedness. CDC had developed 4 preparedness goals, 22 objectives, and 127 indicators, 10 of which specifically addressed smallpox preparedness. CDC intended the indicators to serve as a way to “scorecard” preparedness nationally and state by state and as a way to evaluate compliance with grant guidance (Henderson, 2003). This IOM committee was asked to review the smallpox preparedness indicators (in the context of the larger bioterrorism indicators project) and to advise CDC on their appropriateness and on ways to determine when an indicator had been met. The committee devoted its fifth report, included here as Appendix F, to a review of the indicators and included an assessment of relevant constituencies (state and local public health agencies, health care professionals, health care institutions, and first responders), whose input was solicited at the November 2003 meeting. In that report, the committee stated that preparedness for public health emergencies (including a potential smallpox event) should be part of overall continuous quality improvement of the public health system (IOM, 2003e).

CDC appears to have continued its work on the performance indicators; but at the time the present report was being written, no indicators or other assessment tool had been implemented. In May 2004, at the meeting of the DHHS secretary’s Council on Public Health Preparedness, a CDC official stated that efforts to develop assessment tools were continuing and summarized CDC’s Evidence-Based Performance Goals for Public Health Disaster Preparedness—42 performance goals and 47 measures (Knutson, 2004). In July 2004, at the CDC–American Medical Association First National Congress on Public Health Readiness, the director of CDC’s OTPER noted that CDC’s Evidence-Based Performance Goals for Public Health Disaster Preparedness—more recently, consisting of 35 performance goals and 45 measures—would be available for review on August 31, 2004 (Schable, 2004).

The committee is unaware of the current status of the performance goals and measures. On the basis of available information, the committee has concluded that the nation’s smallpox preparedness has not yet been formally, systematically, and comprehensively evaluated. Therefore, if the smallpox vaccination effort was in fact part of a larger preparedness pro-



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