More than two months after a national advisory panel recommended vaccinating thousands of health care and emergency workers against smallpox as a precaution against a bioterrorist attack, state and local health officials are waiting for the government to announce its official policy. No vaccinations have taken place.
The advisory panel's recommendations are routinely forwarded through the Centers for Disease Control and Prevention to the secretary of health and human services. A spokesman said Friday that Tommy G. Thompson, the secretary, had made no decision.
The government has never rejected or significantly modified any recommendation from the panel, known as the Advisory Committee on Immunization Practices, CDC officials said.
In responding to a federal government request, the advisory panel sped up the end of its deliberations to June from October. Now "it's a hurry up and wait" situation, said the panel's chairman, Dr. John F. Modlin of Dartmouth Medical School.
Responsibility for carrying out any plan and approving who gets the vaccine will fall on state and local health departments. But no state can begin until the federal government, which owns all stocks of the vaccine, releases it.
On June 20, the panel unanimously rejected a proposal to offer vaccine to every American and recommended immunizing about 15,000 "first responders" - the health care and law enforcement workers who would be most likely to respond to a biological attack.
But in early July, some federal officials said that they would soon vaccinate 500,000 first responders.
Jerome M. Hauer, acting assistant secretary for emergency preparedness at the Department of Health and Human Services, said at that time that the agency hoped to send planning documents on how best to conduct mass vaccinations to cities and states within two weeks.
Officials now say that announcement was premature.
"Jerry was jumping the gun," and the material has not been sent, said William Pierce, a department spokesman. The decision has been slowed in part by vacations and is expected within weeks, Pierce said.
Bush administration officials have debated whether to offer smallpox vaccinations to all Americans, as some people have advocated, or to limit them as the committee recommended.
President Bush faces a health issue believed to be a first - weighing the risks of administering a dangerous vaccine to protect against a disease that exists only as an unquantifiable threat.
Last month, Bush said that in considering his options he was concerned about calling for a national vaccination program that could cause death.
The smallpox vaccine can lead to serious and potentially fatal complications, especially in people with impaired immune systems. The virus from which the vaccine is derived, a cousin of the smallpox virus, can spread from recipients to people with whom they come in contact and can cause life-threatening complications among them.
Because the United States stopped routine smallpox vaccinations in 1972, tens of millions of younger Americans have never been vaccinated against a disease that can kill up to 30 percent of its victims. It is unclear how well protected those people who received vaccinations decades ago are.
The World Health Organization declared smallpox eradicated in 1980 and has allowed the United States and Russia each to freeze a stock of smallpox virus. But because the former Soviet Union is believed to have weaponized smallpox virus, the fear is that terrorists or a few countries like Iraq have obtained the virus.
In light of the new threat, Bush administration officials have recently taken a fresh look at data concerning the complications from vaccinations when they were routine in this country. The focus was on the risk of a vaccine recipient inadvertently transmitting the virus to other people, and the data were both reassuring and disconcerting.
The review showed that adults who were vaccinated rarely transmitted the vaccine virus to other people. But experts say they do not know how valid the findings are today when many more people are vulnerable to such infection because they have impaired immune systems from treatment for cancer, HIV infection and other conditions.
More disturbing were the data concerning risks among people with a common skin condition, eczema. People with it, or who have had it, are at higher risk of complications from the smallpox vaccine. The rate was one case of complications per 100,000 vaccinations, a figure that exceeds the risk of paralysis from the oral polio vaccine. The government stopped oral polio vaccinations because it considered the risk too high.
Now state officials want "what amounts to political clearance" before vaccinating health care workers, said Dr. J. Michael Lane, a retired CDC smallpox epidemiologist.