Comments About the Guidance
The continuation guidance issued May 2, 2003 outlines three elements of smallpox preparedness (DHHS, 2003b).4 In its review, the committee has focused largely on the first element, “preparing key responders before an event occurs,” and noted that jurisdictions may define both “preparing” and “key responders” differently (DHHS, 2003b).
Part of the “preparation of key responders” (DHHS, 2003b: 2) occurred when health care and public health response teams were trained and vaccinated as part of what has previously been called “phase I” of the pre-event vaccination plan. As the committee has learned (ASTHO, 2003; Judson, 2003; Madlock, 2003; Selecky, 2003), state and local jurisdictions differ in their definitions of key responders, and the decisions about what preparation means. As noted, we will address this in a forthcoming report. The committee believes it is important that in addition to facilitating expanded vaccination if states conclude it is needed for preparedness, CDC should also facilitate the other smallpox preparedness activities (e.g., training, planning) of states that decide they have enough personnel vaccinated at this time.
The guidance contains several areas that may require clarification either because they provide insufficient direction for state programs, or may not be consistent with the overall tenor of the guidance documents. Several such items are found in Annex A of the guidance (DHHS, 2003b).
First, page 2 states that since smallpox could appear in any hospital, “considerations must be made to ensure each facility has an acceptable number of teams vaccinated.” Although many hospitals have formed and vaccinated response teams, this statement seems to imply that all hospitals need vaccinated response teams in order to be prepared, but this differs from the decisions and plans made by some jurisdictions and their partners. This guideline needs clarification or restating to call for planning to ensure each facility has the ability to train, and where applicable, train and vaccinate, identified individuals and teams pre-event, and that all facilities have access to vaccine and plans for vaccination of their employees post-event or if the threat level rises.
Second, on page 5 the development of a comprehensive smallpox response plan is described as including post-event plans from “participating hospitals.” It is unclear how “participating” is being defined. If it refers to hospitals that have vaccinated personnel, it should also be described how hospitals that choose not to participate in pre-event vaccination will be included in the planning process.
Third, page 3 provides a list of the types of personnel to be trained and vaccinated “in the following order.” If these categories are indeed to be prioritized in this way, it is unclear why vaccinating security staff pre-event is more important than vaccinating health care providers. Furthermore, it is not clear in this section what type of staff should be trained as vaccinators.
Fourth, on page 4, the guidance states that the public should be assured that public health has the capacity to “fully vaccinate the entire population within a short period of time once smallpox has been identified” and on page 6 of 7, that large-scale vaccination is to be “rapidly” executed. State programs might benefit from more specific guidance about the time frame for which they should aim.
The committee also noticed that the final enhanced capacity described in Focus Area B corresponds to one of the ingredients of smallpox preparedness identified in our phone discussions with local and state programs (“working links between health department staff and key individuals and organizations engaged in healthcare, public health, and law enforcement”) (personal communications to staff, April 21–29, 2003). It is not clear why this important issue has not been identified as a critical capacity; preparedness appears to require working relationships with hospital administrators, fire, emergency and law enforcement officials, and many others.
In closing, the committee expresses its thanks for the opportunity to be of assistance to CDC and its partners. It would like to reiterate its call for a pause to facilitate evaluation and planning before moving on to more widespread voluntary vaccination of other types of personnel. Furthermore, the committee hopes its comments on the recently released guidance are helpful as states prepare their responses, and as CDC evaluates those responses.
Brian L. Strom,
Kristine M. Gebbie,
Committee Vice Chair
Robert B. Wallace,
Committee Vice Chair
Committee on Smallpox Vaccination Program Implementation