Bioterrorism was identified as a real threat well before the 9/11 attacks, but increased fear developed following the events of 9/11. Anthrax was the first major bioterrorism event, with cases identified in New York, Washington, D.C., and Florida that were said to have been spread through the mail; this spawned mass hysteria among U.S. citizens. Hospitals began stockpiling Ciprofloxin in order to prepare for a potential anthrax attack/ exposure. Emergency Departments were overwhelmed with patients fearing that they were exposed to anthrax and demanding prescriptions for Cipro to protect themselves and their families. The potential exposure of Anthrax through a bioterrorist attack instilled great fear. The real threat and subsequent danger, however, would lie in the potential exposure to smallpox. Smallpox virus, although eradicated worldwide, is still kept alive and viable in the event of an outbreak where vaccine would need to be mass produced. According to the Centers for Disease Control and Prevention (CDC, 2003), “Although smallpox was declared globally eradicated in 1980, there is concern that smallpox virus may exist outside the two WHO-designated repository laboratories” (p.1). This concern about a potential bioterrorist attack prompted the U.S. House of Representatives, House Select Committee on Homeland Security to mandate the smallpox initiative. Unfortunately, the intended response to this initiative was less than what was expected and the initiative failed. Through the efforts of the state and local DOHMH, the plan was to vaccinate 500,000 first responders in 30 days; however, after one year, only 40,000 were actually vaccinated (U.S. House of Representatives,
House Select Committee on Homeland Security, 2004). Three key factors attributed to this failure were identified: insufficient allocation of resources, an inadequate compensation plan for healthcare workers suffering potential side effects from the vaccine, and healthcare workers and the public’s perceived lack of urgency with regard to a smallpox threat (U.S. House of Representatives, House Select Committee on Homeland Security, 2004). The following case study describes the smallpox initiative of the NYC DOHMH and the medical center’s work in following the directive according to the pull POD model.

In October 2002, the NYC DOHMH issued a directive that was part of a federal mandate to vaccinate the 500,000 healthcare workers who would serve as first responders in the event of a bioterrorist attack involving smallpox. Part of this initiative provided education to staff in select hospitals in the NYC area for case identification, surveillance, preparation, and planning in the event of a bioterrorist attack, and to provide training for physicians and nurses to serve as first responders. These first responders would be vaccinated and then trained by the DOHMH staff to be certified as vaccinators as well.