In its fifth letter report, the Committee on Smallpox Vaccination Program Implementation makes several recommendations to the Centers for Disease Control and Prevention related to the draft smallpox readiness indicators (part of a larger set of public health emergency preparedness indicators), scenarios for testing the relevance of the smallpox readiness indicators, and selected aspects of the overall smallpox preparedness and vaccination program.

The committee offers seven key messages in this report:

1. Preparedness must include a greater emphasis on planning, management, and decision-making.
2. Readiness to respond to public health emergencies (including smallpox emergencies) should be part of overall continuous quality improvement of the public health system.
3. CDC should address its immediate need of measuring cooperative agreement compliance with a concise and simple set of indicators, and then use this set of indicators as the foundation of a longer, deliberative, national process to develop measures that address the full range and appropriate balance of preparedness activities. 
4. Federal agencies bear unique responsibilities in emergency response, and they should be held accountable and assessed on their progress, similar to their state and local counterparts.
5. Public health readiness indicators need to address each of the distinct roles of federal, state, and local jurisdictions in the planning for and response to a public health or, specifically, smallpox emergency. 
6. The current set of readiness indicators provides a useful start to measuring preparedness, but many indicators seem too broad and redundant, and not based on any evident framework, such as one common to the public health system.
7. The draft readiness indicators do not reflect the significance of active and sustained collaboration and communication among the public health system, the health care system, first responders, and the community (conceived in the broadest sense).