- The Washington Times - Monday, May 12, 2003

While the SARS outbreak demonstrated how well public health officials can mount a coordinated, comprehensive response to an emerging epidemic, the ongoing smallpox vaccination campaign has showed how public health resistance, coupled with confusing and contradictory federal guidance, can create a muddle of ill-preparedness.

There’s no doubt that the smallpox inoculation program is in sorry shape. According to the latest numbers from the national Center for Disease Control, fewer than 35,000 public health officials have been vaccinated — about 7 percent of the government’s target for just the first month of the immunization campaign, which started in late January. As a consequence, the CDC has quietly reduced its immunization expectations by 90 percent. Previously, it said that 500,000 vaccinated individuals would be needed for an adequate response to a smallpox attack. Now, it claims that such a response could be produced by just 50,000 vaccinated individuals.

However, the CDC has not explained how it arrived at its new targets, nor has it even asked states to change their immunization plans. Besides, the question has never been how few health care workers would be sufficient to respond to an attack, but how much protection citizens should have.

So, how have we reached this alarming state? To find out, the General Accounting Office conducted an investigation at the behest of chairman of the Senate Governmental Affairs Committee, Sen. Susan Collins, Maine Republican. While this page has focused on the reluctance of public health professionals to expose themselves to risks from taking the vaccine, the GAO study, which was released last week, makes it clear that that is only part of the problem.

Specifically, the GAO study revealed that bureaucratic incompetence has played a significant role in creating the mess. Several critical guidelines didn’t arrive until after the vaccination campaign officially began, and some of those that arrived beforehand offered contradictory guidance. It was only after the start of the campaign that the CDC issued its first cost estimates, and those were badly wide of the mark. While CDC officials estimated that the immunizations would cost $13 per head, the Association of State and Territorial Health Officials and the National Association of County and City Health Officials estimated that the average cost of each shot would be more than $200, if pre-planning and follow-up activities were included.

While there is hope that the president’s signature on the compensation package, which passed Congress, may increase the number of immunization volunteers, the gains seem likely to be modest. However, even if public health officials were suddenly to begin volunteering in droves, the money for more vaccinations might not be there, since state and local officials have already committed most of their smallpox vaccination dollars to other bioterrorism preparedness programs. That must not be allowed to happen to the $100 million that Health and Human Services Secretary Tommy Thompson released last week for smallpox protection and the public health infrastructure.

What is evident from all this is that the government cannot have it all ways on smallpox immunizations. It cannot have a completely voluntary vaccination campaign and still have maximum national preparedness. It cannot have maximum safety with minimum guidance. It will not reach vaccination targets without supplying realistic cost estimates. It cannot depend on select sets of unwilling elites to provide for the common defense against smallpox.

The Governmental Affairs Committee plans to continue monitoring the smallpox vaccination program closely, and it should. The SARS response proved that the public health community can be extremely effective. It must now find a way to be as effective on smallpox as it has been on SARS.



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