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2002 Releases

As Experts Debate the Need for Voluntary Smallpox Vaccination, Three in Five Americans Say They Would Get Vaccinated, Even Though No Smallpox Cases Have Been Reported

For immediate release:  June 05, 2002 

BOSTON, MA — Although not a single case of smallpox has been reported in the United States, three in five Americans (59%) surveyed by the Harvard School of Public Health and Robert Wood Johnson Foundation say they would get vaccinated as a precaution against a bioterrorist attack using smallpox if a vaccine were made available to them. This is the case even though people were told that the vaccination may produce serious side effects in a small number of cases.

If cases of smallpox were reported in their own community, more than three-fourths (81%) of Americans say they would get vaccinated. This includes the 59% who had already said they wanted to get vaccinated in the near future, even without cases having been reported, as well as an additional 22% who became interested in vaccination once local cases were mentioned. One in ten (9%) would not get vaccinated even if an outbreak of smallpox occurred in their community.

These findings, based on interviews with 2,000 Americans nationwide, come at a time when two federal government advisory committees of experts—the Advisory Committee on Immunization Practices and the National Vaccine Advisory Committee—are debating whether or not voluntary smallpox vaccinations should be offered to the public. Also, starting on Thursday, June 6, in New York City and San Francisco, the Centers for Disease Control and Prevention are conducting a series of public forums on the use of the smallpox vaccine. ( )

"The survey results also raise the question of whether or not the country should move ahead with voluntary vaccination of frontline workers, such as doctors, nurses, and emergency personnel," said Robert J. Blendon, professor of Health Policy and Political Analysis at the Harvard School of Public Health. "If there were a bioterrorist attack using smallpox, millions of Americans would want to find health professionals to vaccinate them. If the professionals themselves have not been vaccinated, it could lead to serious delays and public panic."

Level of Public Concern

The substantial public interest today in receiving a smallpox vaccination grows in part from continuing fears about a future bioterrorist attack. Nine months after the September 11th attacks, more than four in ten (43%) report being worried about a future attack using smallpox, down from 53% in November 2001. About half (49%) of women, compared with 36% of men, are currently worried about such an attack. The interest in vaccination may also reflect Americans' familiarity with the smallpox vaccine. Nearly three in five Americans (56%) report having been vaccinated earlier in their lives.

In the near run, the public sees little risk that they or a family member will get smallpox. Only one in twelve Americans (8%) believes that they or someone in their immediate family is likely to contract smallpox during the next 12 months. This compares with 20% who believe they or a family member are likely to be injured in some other type of terrorist attack.

Most Americans (74%) are at least mildly optimistic that they would survive if they contracted smallpox and received immediate medical care. Forty-four percent see it as very likely that they would survive, while 30% thought it somewhat likely.

Confidence in the Health System and Trust in Public Officials

The public is also somewhat optimistic that adequate planning, preparation, and professional education have taken place in their community in regards to a possible smallpox attack. Most Americans (84%) report confidence that their own doctor can recognize the symptoms of smallpox. Almost half (45%) are very confident.

About two-thirds of Americans (70%) believe that their local hospital emergency room is prepared to diagnose and treat people who have smallpox. However, this includes only 23% who think their local ER is very prepared. Similarly, two-thirds (66%) are confident that their local health department is prepared to prevent smallpox from spreading if there were an outbreak of the disease, but this includes only 19% who think the local health department is very prepared.

If they had symptoms of what they thought might be smallpox, most Americans would seek help from the traditional health care system. The most common place to turn for diagnosis or treatment would be their own doctor or medical clinic (83%), followed by a hospital emergency room (62%) or outpatient department (52%). Very few Americans (27%) would seek assistance from a public health department clinic.

The survey finds that there is no single spokesperson the public most trusts on these issues. When asked, in the event of an outbreak of disease caused by bioterrorism, which of six public officials they trusted most to provide correct information about how to protect themselves and their families from the disease, 43% said a senior scientist from the Centers for Disease Control. No other official was chosen by more than 16%. The other choices were the heads of the Department of Health and Human Services, Office of Homeland Security, and FBI, the U.S. Surgeon General, and the city or state health commissioner.

Asked whom they trusted most to provide correct information about where to go if they were exposed to a disease caused by bioterrorism, Americans were nearly evenly split between the CDC (28%) and their city or state health commissioner (26%). Nineteen percent chose the head of the Department of Health and Human Services.

Public Knowledge and Beliefs about Smallpox

Americans' knowledge about smallpox is mixed. More than three-fourths (85%) know that smallpox is contagious. Many believe that smallpox is easily spread. For instance, 90% know that if someone has contracted smallpox and has the symptoms, they should be kept isolated from uninfected people.

However, less than half (43%) of Americans know that if a person has been exposed to smallpox but does not have symptoms, getting a vaccination would prevent the person from coming down with the disease. Only about one-third (32%) know that once a person develops symptoms of smallpox, there is no cure.

"This is the central issue for public health education," said Blendon. "Americans need to know that according to experts, if people are exposed to smallpox but do not yet have symptoms, an immediate vaccination will help protect them against the disease. The message is that you should not wait until you get sick. If you have been exposed, go get vaccinated right away, because once the symptoms start, there is no treatment to stop the course of the disease."


A minority of Americans believes there would be some episodes of discrimination if there were an outbreak of smallpox. About three in ten (28%) believe that if they had smallpox, their local hospital is likely to refuse them treatment because they might infect other people at the hospital.

In addition, one in six Americans (17%) believes health professionals would discriminate against elderly people. Americans aged 65 and over are no more likely than others to think the elderly would face discrimination.

Only one in eight Americans (12%) think African-Americans would face discrimination from health professionals in these circumstances. However, nearly three in ten African-Americans (28%) believe such discrimination would occur.

Trends in Americans' response to bioterrorism

Since the Fall of 2001 there have been only a few changes in Americans' behavior in response to bioterrorist threats. Most Americans continue to believe that in the near run they or someone in their immediate family is unlikely to contract anthrax or smallpox. Currently, 10% think they or a family member is likely to contract anthrax during the next 12 months, down slightly from 14% in October 2001 shortly after anthrax-laden mail was first discovered, but nearly identical to the 9% figure in November-December 2001.

The proportion of Americans believing that they or a family member is likely to contract smallpox during the next year has remained virtually unchanged: 9% in October 2001, 8% in November-December 2001, and 8% currently.

Decreases have been seen in the proportion of Americans who:

  • are taking mail precautions (from 37% in October 2001 to 24% in May 2002)
  • are avoiding public places and consulting a website for information about how to protect themselves in case of bioterrorism (from 12% each in October 2001 to 7% and 8%, respectively, in May 2002)

Of note, there has been a significant rise, from 5% in October 2001 to 15% in May 2002, in the proportion of Americans who report that they or someone in their family has gotten a prescription for or purchased antibiotics in response to concern about bioterrorism. This suggests that some Americans are stockpiling antibiotics in case of a future bioterrorist attack.

Complete Report and Figures


For further information, please contact:

Robin Herman
Office of Communications
Harvard School of Public Health
677 Huntington Avenue
Boston, MA 02115
Phone: 617-432-4388


This study, the third in a series by the Harvard School of Public Health/Robert Wood Johnson Foundation Survey Project on Americans' Response to Bioterrorism, was designed and analyzed by researchers at the Harvard School of Public Health. The project director is Robert J. Blendon of the Harvard School of Public Health. The research team also includes John M. Benson and Catherine M. DesRoches of the Harvard School of Public Health and Melissa J. Herrmann of ICR/International Communications Research. Fieldwork was conducted via telephone for the Project by ICR/International Communications Research of Media (PA) between May 8 and May 21, 2002. The survey was conducted in three waves with a nationally representative sample of 3,011 adults age 18 and over. Some questions were asked in all three waves (margin of error, plus or minus 2.2 percentage points). Most of the questions were asked in two waves (about 2,000 respondents; margin of error, plus or minus 2.7 percentage points). The questions about precautions against bioterrorism and likelihood of surviving diseases were asked in a single wave (1002 respondents; margin of error, plus or minus 3.9 percentage points).

Possible sources of nonsampling error include nonresponse bias, as well as question wording and ordering effects. Nonresponse in telephone surveys produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, sample data are weighted to the most recent Census data available from the Current Population Survey for gender, age, race, education, as well as number of adults and number of telephone lines in the household. Other techniques, including random-digit dialing, replicate subsamples, callbacks staggered over times of day and days of the week, refusal conversion and systematic respondent selection within households, are used to ensure that the sample is representative.