US Disaster Planners' Attitudes Regarding Preevent Vaccine for First Responders and Point-of-Dispensing Workers

Abstract

Disaster planners' attitudes toward preevent anthrax and smallpox vaccine for first responders and point-of-dispensing (POD) workers have not been examined. An online questionnaire was sent to US Cities Readiness Initiative (CRI) and non-CRI public health disaster planners in 2013. Multivariate logistic regressions were used to assess determinants of belief that first responders and POD workers should be offered the anthrax and/or smallpox vaccine before an event. A total of 301 disaster planners participated. Only half (50.6%, n=126) were aware of the ACIP recommendation that first responders could be offered preevent anthrax vaccine. Many (66.0%, n=164) believed that preevent anthrax vaccine should be offered to first responders. The oldest respondents were least likely to believe anthrax vaccine should be given (OR: 0.27, 0.12, 0.63, p<.001). Fewer disaster planners believed that preevent anthrax vaccine should be offered to POD workers compared to first responders (55.0% vs 66.0%, X²=151, p<.001). Almost 20% (18.3%, n=47) reported having already received preevent smallpox vaccine. Among the unvaccinated (n=210), half (52.0%, n=105) were willing to receive preevent smallpox vaccine if it was offered free of charge. Half (53.4%, n=133) believed that POD workers should be offered smallpox vaccine before an event. Many disaster planners support preevent anthrax vaccination for first responders and POD workers, and about half support preevent smallpox vaccine for POD workers. Jurisdictions should consider partnering with first responder agencies to implement a preevent anthrax vaccination program.

Using an online questionnaire, the authors assessed the determinants of belief that first responders and POD workers should be offered the anthrax and/or smallpox vaccine before an event. Many disaster planners support preevent anthrax vaccination for first responders and POD workers, and about half support preevent smallpox vaccine for POD workers. Jurisdictions should consider partnering with first responder agencies to implement a preevent anthrax vaccination program.

Large-scale biological events, such as an aerosolized release of anthrax or a smallpox bioterrorism attack, would have a devastating impact on peoples' health. For example, the projected mortality rate for a smallpox outbreak in the United States could reach 30% or higher.¹ In addition, mathematical modeling studies have estimated that the costs associated with an anthrax attack would reach $26.2 billion per 100,000 exposed individuals.² The Centers for Disease Control and Prevention (CDC) has identified 15 public health preparedness capabilities as the basis for state and local public health readiness for large-scale biological events; these capabilities fall into the following domains: biosurveillance, community resilience, countermeasures and mitigation, incident management, information management, and surge management.³

Central to each of these capabilities is having sufficient personnel who are willing and able to identify and respond to these events. Potential ways to increase the likelihood of workers' willingness to work during biological events include providing protection through personal protective equipment (PPE), pre- and/or postexposure prophylaxis, and vaccine. In addition, research has found that prioritizing response workers for medical countermeasures when supplies are limited is associated with increased willingness to work.⁴

Regarding the option to immunize high-risk individuals, vaccines exist for both smallpox and anthrax, but preevent considerations for use of these countermeasures are different for the 2 vaccines. In 2001, the CDC's Advisory Committee on Immunization Practices (ACIP) recommended that communities establish smallpox response teams consisting of individuals who would be responsible for managing initial smallpox cases and those designated to administer preevent smallpox vaccine following a bioterrorism attack.^5,6 This was intended to create a cadre of protected workers who could maintain civil order and preserve continuity of operations and government as well as assist in performing ring and/or mass vaccination. Pursuant to these recommendations, the federal Phase I Smallpox Vaccination Program was implemented in January 2003 with the goal of vaccinating 500,000 civilians.⁷ However, because of a lack of dedicated funding for the initiative⁷ and the development of previously unseen adverse effects that may have been associated with the smallpox vaccine (namely cardiac issues), this program was unsuccessful in meeting the goal. In late 2003, ACIP revised its recommendation about preevent smallpox vaccine, and the Phase I Smallpox Vaccination Program was ended.⁸

Anthrax vaccine has also been used in the period before an event for a very limited group of specialized people.^9,10 In 2000, ACIP recommended that high-risk individuals who are likely to have repeated exposures to aerosolized anthrax spores should receive the anthrax vaccine before an event.⁹ This primarily meant laboratory workers, although the guidelines indicated that it could also include military personnel or other people in occupations at high risk of repeat exposures.⁹ Even after the 2001 anthrax bioterrorism attack, ACIP maintained its prior stance that emergency responders did not require routine immunization against anthrax because of the impossibility of calculating an exposure risk for these individuals.¹⁰ The ACIP recommendations were updated in 2009 to indicate that individuals who engage in emergency response activities may be offered voluntary preevent anthrax vaccine if it is administered as part of a comprehensive occupational health program.¹¹ Although ACIP stopped short of recommending preevent anthrax vaccination, their report indicated that preevent vaccine might be more protective than postexposure prophylaxis alone after an anthrax occupational exposure, based on the clinical evidence that multiple vaccinations are often needed before immunogenicity is achieved.¹¹

In its recommendations on the use of anthrax vaccine, the CDC has limited the list of responders to “persons involved in emergency response activities including but not limited to, police departments, fire departments, hazardous material units, government responders, and the National Guard.”¹¹^(p20) However, many other civilians who do not fall into these categories are being trained to assist in critical response and mitigation activities, including the rapid distribution of medical countermeasures through points of dispensing (PODs). These disaster response volunteers may fit ACIP's criteria for being offered voluntary preevent anthrax vaccine. It is unknown whether traditional first responders and public health disaster planners and volunteers are aware of the ACIP recommendations related to preevent anthrax vaccine and whether they believe POD workers should be offered preevent anthrax vaccine. The purpose of this study was to examine disaster planners' attitudes toward preevent anthrax and smallpox vaccine for first responders and POD workers.

Methods

An online questionnaire was sent to US public health disaster planners in summer and early fall of 2013. Recruitment occurred over 3 months, with attempts being made to reach all 456 CRIs and a random sample of 500 non-CRI jurisdictions. Disaster planners were contacted by phone, informed of the study, and asked if they would be willing to participate. Phone numbers were obtained from agency websites; recruitment calls began by asking the person answering the phone if recruiters could speak with the person responsible for POD planning for the jurisdiction. Recruiters were then transferred to the phone of the person responsible for disaster planning; if no one answered that phone, a voice message was left. If the disaster planner was reached and agreed to participate, a recruitment email that included a link to the online questionnaire was sent. The questionnaire was administered through Qualtrics Software version 2013 and was anonymous. A modified Dillman's Total Design Method¹² was used to maximize response rates; this consisted of sending a follow-up email 2 weeks after the initial recruitment email to maximize response rates. The recruitment plan also included leaving up to 3 voice messages with each jurisdiction and/or disaster planner, but time constraints prevented this from occurring consistently. The Saint Louis University Institutional Review Board approved this study.

Instrument

This study was part of a larger survey that examined the preparedness of US open and closed PODs for mass dispensing of vaccines.¹³ No existing research measuring attitudes toward preevent vaccine for POD workers was found in the literature when the instrument was developed, although a report discussing these topics was identified.¹⁴ CDC's ACIP recommendations^8,11 and existing instruments measuring seasonal influenza and H1N1 influenza vaccine uptake^15,16 were used to develop items related to attitudes regarding preevent anthrax and smallpox vaccination for POD workers. In addition, instrument items were developed and refined based on an Institute of Medicine report summarizing a mass dispensing workshop.¹⁴

Ten US public health professionals responsible for PODs in their community pilot-tested the instrument and assessed content validity. Pilot testing feedback was used to finalize the instrument. The instrument measured: (1) awareness of ACIP recommendations, (2) attitudes toward preevent use of anthrax vaccine for first responders, (3) attitudes toward preevent use of anthrax and/or smallpox vaccine for POD staff and volunteers, and (4) perceived benefits and barriers to preevent anthrax and/or smallpox vaccine. In addition, demographic variables were collected. The existence of preevent vaccination programs in jurisdictions was not assessed; we examined only attitudes toward these programs.

Data Analysis

All data analyses were performed using the R statistical program.¹⁷ Descriptive statistics were conducted with all variables. The primary binary outcomes of interest assessed were: (1) awareness of ACIP's 2010 recommendation that first responders can be offered the anthrax vaccine preevent, (2) belief that first responders should be offered the anthrax vaccine preevent, (3) belief that POD workers should be offered the anthrax vaccine preevent, and (4) belief that POD workers should be offered the smallpox vaccine preevent. Each outcome was analyzed with respect to jurisdiction and respondent demographic variables using chi-square tests (univariate analysis) and logistic regression (multivariate analysis). The model for belief that first responders should be given the anthrax vaccine before an event also included awareness of ACIP's 2010 recommendation for the vaccine. Good model fit, indicated by a nonsignificant chi-square value, was calculated with the Hosmer and Lemeshow goodness-of-fit test for each regression. Nonsignificant variables (those with p-values greater than 0.05) were not included in the final models; only final models are reported.

Results

Recruiters spoke with 632 individuals who were invited to participate in the study; 20 declined. The 612 consenting individuals were sent a survey link, and 301 participated. Forty-four subjects were excluded because of excessive missing data, yielding 257 completed surveys (response rate: 41%). Nearly all respondents work full-time (85%, n=218), and most (68%, n=173) were female. Three-quarters had a bachelor's degree or higher (76%, n=196). Of those who provided information about their jurisdiction (n=241), most (61%, n=147) work in a CRI jurisdiction. Very few (4.3%, n=11) work in a tribal jurisdiction. Over half (53.5%, n=129) covered jurisdictions with populations of fewer than 100,000, with another 28.2% (n=68) covering jurisdictions with populations of 100,000 to 500,000. Approximately half (49%, n=118) had some formal medical background: 23% (n=60) were nurses, 14% (n=35) were emergency medical technicians (EMTs), and 9% (n=23) were physicians. Most respondents had a fairly significant amount of work experience and had been in their current role for more than a few years. One-third (35%, n=90) reported 6 to 10 years' experience, and another third (33%, n=84) had 11 or more years' experience in the field. Almost a third (27%, n=70) have been in their current role for 6 to 10 years, and another third (37%, n=94) have been in their current role for 2 to 5 years. A full list of participant demographics is outlined in Table 1.

Table 1.

Participant Demographics

Individual Characteristics	% (N) ^a
Gender (female)	65.1 (157)
Employment status (full-time)	90.5 (218)
Age
≤35 years	22.0 (53)
36-45 years	20.3 (49)
46-55 years	27.0 (65)
≥56 years	30.7 (74)
Education level
Associate's degree or less	18.6 (45)
Bachelor's degree	41.5 (100)
Master's degree or higher	39.8 (96)
Formal medical education (yes)	46.0 (118)
Registered nurse	50.8 (60)
Emergency medical technician	29.7 (35)
Physician	1.7 (2)
Other	17.8 (21)
Work experience (in years)
≤1 year	3.7 (9)
2-5 years	24.1 (58)
6-10 years	37.3 (90)
≥11 years	34.9 (84)

Jurisdiction Characteristics	% (N)^a
Cities Readiness Initiative (CRI) jurisdiction	61.0 (147)
Tribal government	4.6 (11)
Population
≤100,000	53.5 (129)
100,001-500,000	28.2 (68)
500,001-999,999	11.2 (27)
≥1 million	7.1 (17)

Denominator varies due to missing/incomplete data.

Awareness of ACIP Recommendation Change

Only half of disaster planners (50.6%, n=126) were aware of the 2010 change in ACIP recommendation that first responders could be offered preevent anthrax vaccine. In univariate analysis, more CRI disaster planners were aware of the ACIP recommendation change compared to non-CRI respondents (55.1% vs 41.5%, X²=4.3, p<.05). However, being in a CRI jurisdiction was highly correlated with population, and population was a more significant predictor in multivariate analysis; therefore, CRI was not included in the multivariate analysis. Factors associated with knowledge of the ACIP recommendation change included jurisdiction population and US geographic region (Table 2). Disaster planners from more populated jurisdictions were more likely to be aware of the recommendation change than those from less populated areas. In addition, respondents in southern states were more likely to be aware of the recommendation, and those in the west were less likely to be aware.

Table 2.

Factors Related to Awareness of the 2010 ACIP Statement that First Responders Can Be Offered Preevent Anthrax Vaccine from Logistic Regression

	OR	95% CI	p-value
Population
≤100,000	1	—	—
100,001-500,000	1.53	(0.82, 2.85)	NS
500,001-999,999	4.22	(1.58, 11.26)	0.00
≥1 million	3.79	(1.10, 13.01)	0.03
US Census region
Pacific	1	—	—
Mountain	4.30	(1.13, 16.29)	0.03
West North Central	1.81	(0.51, 6.40)	NS
East North Central	1.96	(0.55, 7.00)	0.30
Middle Atlantic	1.18	(0.23, 6.12)	NS
New England	2.82	(0.72, 10.95)	NS
West South Central	6.72	(1.35, 33.42)	0.02
East South Central	2.14	(0.48, 9.49)	NS
South Atlantic	5.61	(1.42, 22.21)	0.01

OR=odds ratio; CI=confidence interval; NS=nonsignificant.

Attitudes Regarding Preevent Vaccination

Approximately three-quarters of disaster planners (77.1%, n=192) believed that preevent vaccination of POD staff and volunteers would protect them from disease during a biological event. Women were more likely than men to believe that preevent vaccination would protect POD workers (82.2% vs 70.2%, X²=4.5, p<.05). Most disaster planners (83.9%, n=209) believed that preevent vaccines should be provided free of charge to POD workers. Those in non-CRI jurisdictions were more likely than those in CRIs to believe that preevent vaccines should be free (90.4% vs 81.0%, X²=4.0, p<.05). Less than 20% (16.9%, n=42) believed that preevent vaccines are unnecessary for POD staff and volunteers. There were no differences found between those who believed that preevent vaccines are unnecessary in relation to gender, medical training status (physician, nurse, or emergency medical services personnel versus those without any medical training), jurisdiction size, or other demographic variables.

Attitudes Regarding Preevent Anthrax Vaccine

Many disaster planners (66.0%, n=164) believed that anthrax vaccine should be given to first responders before an event, and this belief was independent of awareness of the ACIP recommendation. From multiple logistic regression, only the respondent's age was a significant predictor of belief that first responders should be offered the anthrax vaccine preevent, with the oldest respondents being least likely to believe the vaccine should be given (Table 3). Approximately half (55.0%, n=137) believed that POD workers should be offered the anthrax vaccine preevent. Significantly more disaster planners believed that preevent anthrax vaccine should be offered to first responders compared to those who believed it should be given to POD workers (66.0% vs 55.0%, X²=151, p<.001). Predictors of belief that POD workers should be offered preevent anthrax vaccine included reporting that POD planning priorities are determined by the jurisdiction's risk analysis and having fewer years of work experience (Table 3).

Table 3.

Determinants of Belief that First Responders and/or POD Workers Should Be Offered Preevent Anthrax and/or Smallpox Vaccine

	Preevent Anthrax Vaccine for First Responders		Preevent Anthrax Vaccine for POD Workers		Preevent Smallpox Vaccine for POD Workers
	OR (95% CI)	p-value	OR (95% CI)	p-value	OR (95% CI)	p-value
Age
≤36 years	1			NIM		NIM
36-45 years	0.64 (0.25, 1.64)	NS		NIM		NIM
46-55 years	0.49 (0.21, 1.15)	NS		NIM		NIM
≥56 years	0.27 (0.12, 0.63)	<.001		NIM		NIM
POD planning priorities from RA		NIM	2.14 (1.26, 3.64)	<.001		NIM
Male		NIM		NIM	.56 (.32, .96)	<.05
Years of work experience
≤1 year		NIM	1		1
2-5 years		NIM	.27 (.03, 2.38)	NS	.17 (.02, 1.44)	NS
6-10 years		NIM	.19 (.02, 1.61)	NS	.16 (.02, 1.33)	<.05
≥11 years		NIM	.12 (.01, 1.04)	=.05	.11 (.01, 0.89)	<.05

OR=odds ratio; CI=confidence interval; NS=nonsignificant; NIM=not included in model because it was NS; RA=risk analysis.

Very few disaster planners (3.2%, n=8) reported having already received preevent anthrax vaccine. Of those who have not already been vaccinated (n=241), about half (58.1%, n=140) were willing to receive preevent anthrax vaccine if it were offered free of charge. There were no differences found between those who would be willing to receive preevent anthrax vaccine in relation to awareness of the ACIP recommendation, gender, medical training status, jurisdiction size, or other demographic variables.

Attitudes Regarding Preevent Smallpox Vaccine

Almost 20% of disaster planners (18.3%, n=47) reported having already received preevent smallpox vaccine. Of those who have not already been vaccinated against smallpox (n=210), half (52.0%, n=105) reported being willing to receive preevent smallpox vaccine if it were offered to them free of charge. Significantly fewer would be willing to receive preevent smallpox vaccine if they had to pay for it than if they were offered it free of charge (33.2% vs 52.0%, X²=87.8, p<.001). There were no differences found between those who would be willing to receive preevent smallpox vaccine in relation to gender, medical training status, age, education level, or other demographic variables.

Approximately half of all disaster planners (53.4%, n=133) believed that POD workers should be offered smallpox vaccine preevent. Only gender and years of work experience were significantly associated with belief that POD workers should be given preevent smallpox vaccine, with more women and those with fewer years of work experience supporting it compared to men or those with more work experience (Table 3). No other differences were found, including when examining the disaster planner's smallpox vaccination status. Disaster planners were significantly more likely to believe that POD workers should be offered preevent anthrax vaccine compared to preevent smallpox vaccine (55.0% vs 53.4%, X²=108.7, p<.001).

Discussion

This study found that only half of all disaster planners were aware of the CDC ACIP change in recommendation indicating that first responders can be offered preevent anthrax vaccine. No research could be found describing the extent to which first responders are currently aware of or being offered preevent anthrax vaccine since the change in ACIP recommendations. It seems likely that many first response agencies, like the disaster planners in this study, may not be aware of the opportunity to offer anthrax vaccine to their staff, although this has not been assessed. Without more widespread awareness of the preevent vaccine opportunity, it is unlikely that many first responders will be given the option of being vaccinated.

Preevent vaccination represents a potentially important component of community preparedness for anthrax bioterrorism attacks. It not only raises awareness about the possibility of an attack,¹⁸ but it also creates a protected workforce who can safely respond to incidents that may involve antibiotic-resistant anthrax strains, larger exposures compared to naturally occurring events, and/or the reaerosolization of anthrax spores.¹¹ In this study, more than three-quarters of disaster planners reported believing that preevent anthrax vaccination would be protective against disease. Having vaccinated first responders who are protected from disease increases emergency worker surge capacity and resilience in communities.

A logical next step for disaster planners, researchers, and educators is to raise awareness of the opportunity for first responders to receive preevent anthrax vaccine and consider offering it to first response professionals. As ACIP has emphasized, such an opportunity needs to be provided through a comprehensive occupational health program that includes provision of personal protective equipment and administration of postexposure antibiotics, even among those who have been fully vaccinated against anthrax.¹¹ It is also vital that first responders receive accurate and clear information regarding potential occupational exposure risks and possible benefits and adverse effects of preevent vaccination so that they can make an informed decision. In addition, whenever feasible, preevent vaccines should be offered free of charge, as this study's findings demonstrated that the vast majority of disaster planners, especially those who work in more rural and/or less well funded areas, believe it should be.

There are multiple potential reasons why first response agencies may not currently be offering preevent anthrax vaccine to their staff. Agency administrators may not be aware of the change in ACIP recommendations. There are also costs associated with offering preevent vaccine to staff, including the fee for purchasing vaccine and program administration costs for administering the vaccine, performing follow-up on those who were vaccinated, and managing the program. Current ACIP guidelines indicate that preevent anthrax vaccine is given as a 5-dose series with an annual booster.¹¹ This requires a fairly extensive time commitment on behalf of the person being vaccinated and the occupational health program to conduct follow-up to ensure that the person stays on the vaccination schedule.

It is also possible that first response agency administrators may not support preevent anthrax vaccine or believe that their staff would want to be vaccinated because of past controversy regarding the vaccine. For example, a 2008 study conducted with members of the US military found that about half reported that they believed the anthrax vaccine was ineffective and 42% believed it was unsafe.¹⁹ However, this study did not assess perceptions about anthrax vaccine safety or efficacy, so it is unclear what impact this may have on agency administrators' support for preevent anthrax vaccine.

Future research should focus on assessing the extent to which first response agencies are offering preevent anthrax vaccine to their staff and the perceived benefits and barriers to doing so. This information would help inform future interventions, such as targeted education programs and/or infrastructure changes necessary to implement preevent vaccine programs. In 2012, the US Department of Homeland Security proposed a program to offer first responders preevent anthrax vaccine using Strategic National Stockpile stocks that were approaching expiration.²⁰ However, this proposed pilot program is still under discussion and has not yet been implemented.¹⁸

Although the option of offering preevent anthrax vaccine to first responders is clearly outlined in ACIP recommendations, the issue of preevent anthrax vaccine for POD workers is more ambiguous. ACIP states that preevent vaccine is not routinely recommended for those involved in “emergency response activities,” although it may be offered on a voluntary basis.¹¹ The vague part of this recommendation is the definition of an “emergency responder.” The guidelines list a number of potential worker groups to whom this recommendation “might” apply (POD workers not being mentioned), and they also indicate that voluntary vaccination may be offered to those who perform “other activities critical to the maintenance of infrastructure.”¹¹^(p20) Given the lack of specificity in this recommendation, disaster planners could argue that POD workers meet this definition through their role in mass dispensing of medical countermeasures. A little over half of the disaster planners in this study reported that they would support offering preevent anthrax vaccine to POD workers, although the questionnaire did not assess whether the planners believed that POD workers meet the ACIP definition of an “emergency responder,” making them potentially eligible for preevent vaccine.

This issue requires additional investigation. It is unclear whether POD workers would be eligible to receive preevent anthrax vaccine, and there are other potential barriers to offering it to them as well. For instance, although this study found that about half of all disaster planners support preevent vaccine for POD workers and would be willing to receive preevent anthrax vaccine themselves, it is not known if other POD workers, including volunteers from the general public, would be interested in receiving it. It is also not known whether jurisdictions have the infrastructure and resources to implement a preevent vaccine program for POD workers. Future research should examine these issues, as preevent anthrax vaccine for POD workers could have an impact on POD throughput success. Previous studies with healthcare personnel and first responders have found that prioritizing workers to receive event-specific medical countermeasures, such as vaccine or prophylaxis, increases their willingness to work during biological events.^21-23 If preevent vaccination of POD workers translates into more willingness to work when it is time for POD deployment, this could mean the difference between success and failure for a POD to distribute mass medical countermeasures.

A little over half of the disaster planners in this study support offering preevent smallpox vaccine to POD workers and/or volunteers, and approximately the same number would be willing to receive the smallpox vaccine themselves before an event. However, willingness to receive preevent smallpox vaccine dropped significantly if there was a charge associated with receiving it. During the Phase I Preevent Smallpox Vaccination Program, ACIP recommendations indicated that individuals who would be responsible for vaccinating others against smallpox should ideally be vaccinated during the preevent period with a confirmed “take” or, at a minimum, be vaccinated before administering vaccine to others.⁶ Over the course of the Preevent Smallpox Vaccination Program (2002-03), 38,783 civilians²⁴ and 450,293 military personnel²⁵ received the smallpox vaccine. The civilians who received smallpox vaccine consisted primarily of hospital staff and public health professionals designated to be on smallpox response teams.²⁴ The current preparedness status of smallpox response teams in the US is unknown, although the CDC website provides information regarding which vaccination clinic staff should be prioritized to receive smallpox vaccine during a proposed preevent smallpox vaccination program.²⁶ Although PODs did not exist during the Phase I Preevent Smallpox Vaccination Program, POD workers—at least those designated to be vaccine administrators at the POD—would fit the criteria for needing to receive preevent vaccine or immediate pre-POD deployment vaccination. At this time, ACIP does not recommend that any additional individuals receive preevent smallpox vaccine because of the unanticipated adverse effects seen during the Phase I Preevent Smallpox Vaccination Program,⁸ except for those who work with the Variola virus in a laboratory setting.⁵

If a smallpox bioterrorism attack were to occur and mass vaccination were to be implemented, vaccinators working at PODs would be prioritized to receive smallpox vaccine according to CDC recommendations.⁵ This provides a great benefit to POD staff, given that the sooner smallpox vaccine is administered after an exposure, the more effective it is at preventing morbidity and mortality. Researchers indicate that smallpox vaccine given within 3 days of exposure significantly reduces the risk of severe illness and death, and even receipt of vaccine 4 to 7 days after exposure is associated with a much lower risk of death.¹ Disaster planners should educate current and potential POD staff and volunteer recruits about this benefit, as it should increase their willingness to work during a smallpox outbreak, which improves community resilience.

An interesting finding from this study is that disaster planners' years of work experience predicted support for offering POD staff preevent anthrax and smallpox vaccine, with those who had the most work experience being less likely to support offering POD staff preevent vaccines compared to those with less work experience. Even more interesting is that there was no relationship between years of work experience and support for offering preevent anthrax vaccine to first responders. Although the reasons for these disparate attitudes are not known, they may be related to the fact that ACIP has already stated that emergency responders can be offered preevent anthrax vaccine, and disaster planners of all ages may see the clear connection between the term “emergency responder” and first responders. Given that ACIP has not taken a stand on preevent anthrax vaccination for POD workers, more experienced disaster planners may exclude POD workers in their definition of the term “emergency responder.” There may also be other factors involved. For example, more experienced disaster planners may anticipate the logistical challenges in broadening the definition of the term “emergency responder” to include POD workers and the need to then make preevent vaccine available to them, or they may better understand the potential role of preevent vaccination in recruiting and retaining POD workers. These disparate attitudes among disaster planners should be evaluated in future studies.

The major strength of this study is that it is the first to examine attitudes regarding preevent anthrax and smallpox vaccine for POD workers and volunteers. It is also a nationwide study involving communities of all sizes, including not only CRIs, but also a random sample of non-CRIs. Some limitations should also be noted. The primary limitation is the moderate response rate, which decreases generalizability. However, the nationwide sample and use of randomization for recruiting non-CRIs helps increase generalizability. There were also significantly more respondents from CRI jurisdictions compared with non-CRI jurisdictions, although approximately equal numbers were approached for recruitment. There is a slight risk of bias because of this; however, this risk is minimized given that there were no reported differences between preevent vaccination attitudes in CRI versus non-CRI jurisdictions.

Conclusion

Many disaster planners are supportive of preevent anthrax vaccination for first responders and POD workers, although awareness of the ACIP recommendation change that would allow first responders to be offered this vaccine is low. Jurisdictions should consider partnering with first responder agencies to implement a preevent anthrax vaccination program, making sure that it is administered through a comprehensive occupational health program and includes education on the risks and benefits of vaccination. Provision of preevent anthrax vaccine for POD staff and volunteers should result in better community resilience for large-scale biological events.

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