Special Report: Humbled CDC Seeks Reinvention, Culture Change

By Gary Evans, Medical Writer

The CDC has taken responsibility for its haphazard response to the COVID-19 pandemic in the United States, admitting to mistakes and miscalculations that often directly affected healthcare workers.

The agency is making several changes as it tries to “reset” and consider the recommendations by an independent consultant who conducted an internal review and interviewed more than 100 CDC employees. (For more information, see the related story in this issue.)

“For 75 years, CDC and public health have been preparing for COVID-19, and in our big moment, our performance did not reliably meet expectations,” CDC Director Rochelle Walensky, MD, said in a statement.¹ “I want us all to do better, and it starts with CDC leading the way. My goal is a new, public health action-oriented culture at CDC that emphasizes accountability, collaboration, communication, and timeliness.”

In a video message to CDC employees, she was blunter, saying, “To be frank, we are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications.”²

There were many complaints about confused and delayed public health messaging. Indeed, one of the recommendations from the internal review is to release findings more quickly and increase transparency about the agency’s current knowledge of the situation.

But someone who was transparent at the beginning of the pandemic was more or less silenced — and eventually left the CDC. On Feb. 26, 2020 — with SARS-CoV-2 just emerging in the United States — Nancy Messonnier, MD, then director of CDC’s National Center for Immunization and Respiratory Diseases, gave a stark and prescient warning of what was to come. It was not confusing. Indeed, it seems to meet the calls now for quick dissemination of critical information. She advised preparation for school closures, remote work, and a transition to telehealth, all of which came to pass as the pandemic unfolded.

“I understand this whole situation may seem overwhelming and that disruption to everyday life may be severe,” Messonnier said at the press conference.³ “But these are things that people need to start thinking about now. I had a conversation with my family over breakfast this morning and I told my children that while I didn’t think that they we’re at risk right now, we as a family need to be preparing for significant disruption of our lives. … I’m concerned about the situation. CDC is concerned about the situation. But we are putting our concerns to work preparing. And now is the time for businesses, hospitals, community schools, and everyday people to begin preparing as well.”

Sounding the alarm early in the pandemic did not go over well with a Trump administration that was downplaying the SARS-CoV-2 threat.³ Messonnier rarely spoke at press briefings thereafter before leaving the CDC in May 2021. She is now dean of the Gillings School of Global Public Health at the University of North Carolina. Messonnier declined to comment for this story.

Undue Influence

To some extent, the CDC pandemic response under former director Robert Redfield, MD, was undermined by the Trump administration, which took control of the public health messaging and tamped down pandemic response initiatives seen as politically damaging in an election year.

For example, testing — a bedrock public health measure — was frequently discouraged by the administration because it increased the number of cases and made the response look ineffective. In a particularly absurd development, the common-sense measure of wearing a face mask during a respiratory pandemic became a political battleline.

Walensky took the CDC helm in January 2021, but the pattern of mistakes and missteps continued on her watch under the Biden administration. The result after 2.5 years of pandemic pain was more than 1 million Americans dead, by far the most reported by any country.

As of Aug. 20, 2022, the U.S. death toll was 1,043,840. Brazil was the second highest, reporting 683,397 deaths.⁴ The United States also leads the world in monkeypox cases, with the CDC reporting 18,001 cases as of Aug 29.⁵ The next closest country is Spain, with 6,459 cases. CDC’s public reputation will erode further if monkeypox becomes an endemic infection in the United States.

“Trust in the CDC has fallen during the pandemic,” says Monica Gandhi, MD, MPH, professor of medicine at the University of California, San Francisco. “A January 2022 Hart poll found that only 44% of Americans trusted the CDC.”⁶

Still, the CDC’s admission of errors and commitment to transformation may bolster public confidence. “I admire the CDC leadership in that they want to address the messaging concerns during the pandemic and work on this overhaul,” Gandhi says. “We need to rebuild trust in public health and — importantly — be ready for the next public health emergency by examining what worked and didn’t work in our pandemic response.”

Walensky Stopped the Buck

Walensky’s assessment of the CDC’s poor performance sets a solid, sincere tone for the agency’s reinvention. It was a “the buck stops here” moment for the director.

“I think [she] displayed great leadership and courage in ordering this full evaluation of CDC,” says Lawrence Gostin, JD, a law professor at Georgetown University. “If this review leads to better skill sets among CDC staff, improved health communication, and modern data systems, it will be transformative. It is important to stress that meaningful change can’t come only from Atlanta. It must be a whole of government approach, including ample funding from Congress.”

Overall, the CDC’s pandemic response has been weak, and the agency has underperformed in multiple arenas. “Above all, CDC’s health communication has been confusing and constantly changing,” Gostin said. “The CDC was late or even wrong on many key issues throughout the pandemic, including public health guidance on aerosolized spread, masking, isolation, and quarantine. Its decisions about school closures have been roundly criticized.”

The CDC also was behind the curve in genetic sequencing earlier in the pandemic, making it difficult to identify emerging variants of SARS-CoV-2.

“If the CDC can provide a faster turnaround on relevant data, organizations can make risk assessments and hazard control plans,” says Cory Worden, PhD, a health and safety expert based in Houston. “These control [plans] should include user-friendly explanations of needs like respiratory protection programs and contamination control procedures.”

On the other hand, appropriate peer review of data cannot be sacrificed in the name of rapid timelines, Gandhi says. “I am concerned about the idea that the CDC would de-emphasize academic research and publish more quick communications,” she says. “Any data with policy implications should be rigorously peer reviewed. Part of this overhaul should be making data easily accessible to academicians and other researchers for rigorous peer review.”

Mistakes Were Made

The problems began early in the pandemic when the CDC designed and rolled out a SARS-CoV-2 test that was flawed and inaccurate. In contrast, other countries were using a successful test advocated by the World Health Organization. Typically, the CDC has designed its own diagnostics, and did not seek tests from other sources. As the early unidentified cases spread, precious weeks were lost as the CDC worked to correct the test.

In early March 2020, the first healthcare worker infections in the United States were reported at a nursing home in Seattle. As the pandemic continued, thousands of healthcare workers lost their lives to COVID-19, but exactly how many is unknown. A 2020 report by the National Academy of Sciences revealed “no OSHA category counts deaths specifically from occupationally acquired infection. … The absence of a uniform national framework, and inconsistent requirements across states for collecting, recording, and reporting healthcare worker mortality and morbidity data associated with COVID-19 impairs anyone’s ability to make comparisons, do combined analyses, or draw conclusions about the scale of the problem.”⁷

The CDC has redoubled efforts in this area but must extrapolate to some degree from various state reporting systems. COVID-19 also may not be listed as the cause of death. As of Aug. 29 — in what are no doubt underestimates — the CDC said of the confirmed 970,601 cases of COVID-19 in healthcare workers, death status is available for 538,898 (56%). Of those, 2,353 died.⁸

Asleep at the Switch

Many of these healthcare worker infections and deaths occurred during a shortage of personal protective equipment (PPE), particularly N95 respirators. Healthcare workers were concerned and somewhat skeptical when the CDC issued contingency guidelines that said surgical exam masks could be worn while caring for COVID-19 patients, with N95 masks reserved for aerosol-generating procedures.⁹ A recent study comparing surgical masks to N95 respirators over cumulative exposure times revealed “the odds of being SARS-CoV-2-positive were reduced by more than 40% in individuals using respirators irrespective of cumulative exposure.”¹⁰

Hospitals began reprocessing single-use N95 respirators, even though some healthcare workers feared exposure to the decontamination chemicals. A last-ditch — and widely ridiculed — CDC recommendation called for healthcare workers to wear bandanas and scarves if no other masks were available. A petition that garnered more than 1 million healthcare worker signatures included the statement: “I do not know how long it takes to make an N95 mask, but I do know how long it takes to train a physician, a nurse practitioner, a physician assistant, a respiratory therapist, or nurse. We are the supply chain that needs to be protected.” (For more information, see the story in the May 2020 issue of Hospital Employee Health.)

What happened? In retrospect, it appears there was at some level the reckless presumption that N95 respirators were stored in abundance in the Strategic National Stockpile (SNS) or could be rapidly produced and distributed by manufacturers. Neither proved true. Some N95s were in the SNS, but not nearly enough to meet the demand that dramatically increased over a short period. When the pandemic hit, the SNS had not been formally assessed in years, even though it is supposed to be inspected annually, according to an after-action report by the National Academy of Sciences.¹¹

The CDC does not take full blame for that, although they can scarcely distance themselves. They are one of several federal agencies that comprise the Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) that oversees the SNS.

“Agreement is widespread that PHEMCE has fallen short of its mandate over the years,” the National Academy report authors noted. “The annual SNS review has not been conducted since 2016, creating a major vulnerability in our nation’s ability to respond to the COVID-19 pandemic. Months into the pandemic, shortages of PPE, intensive care unit medications, ventilators, and test-kit supplies persisted.”

The lax administration of the PHEMCE was another major public health failing, probably the closest thing to an “asleep at the switch” moment as any in the pandemic. The problem of insufficient PPE was compounded by the lack of a vaccine.

In a move widely seen as further evidence the pandemic response had been politically undermined, the CDC revised SARS-CoV-2 testing guidelines in August 2020, de-emphasizing the need to test asymptomatic people who have been in contact with a case of COVID-19. That caused an uproar, particularly since the CDC had been emphasizing the importance of contact tracing because 40% of cases were asymptomatic. In a “clarification” issued Sept. 18, 2020, the CDC stated “due to the significance of asymptomatic and pre-symptomatic transmission, this guidance further reinforces the need to test asymptomatic persons, including close contacts of a person with documented SARS-CoV-2 infection.”¹²

Full transparency about the CDC guideline process could have helped limit “unnecessary politics, doubt, and confusion,” Worden says. “If the CDC’s data or guidance is late, incomplete, confusing, or otherwise difficult to utilize, organizations and individuals might not know when controls are needed or what to implement.”

In May 2021, the CDC made one of its most highly publicized errors, telling the vaccinated public they could shed their masks and not socially distance in many indoor situations. In wanting to convey a message of progress and optimism while rewarding and encouraging vaccination, it seemed to some critics the CDC was suggesting the pandemic was over. Some warned it would cause confusion, noncompliance, and a possible spike in cases.

An outbreak of the delta variant in Provincetown, MA, a couple of months later showed the virus could cause breakthrough infections in those fully vaccinated, particularly if they were unmasked and indoors. Moreover, those with breakthrough infections could transmit to others, so the much-maligned mask was called back into action. However, this was an irreversible error, as many people never went back to masking. It should be noted the omicron variants currently circulating also can cause breakthrough infections and are more transmissible than delta.

The CDC was slow to be convinced SARS-CoV-2 was an airborne pathogen, continuing to recommend droplet precautions until the accumulating evidence caused another reversal. Last year, the CDC reported emerging science shows transmission of SARS-CoV-2 airborne viral particles can occur beyond six feet, particularly in enclosed, poorly ventilated spaces. This risk increases in “enclosed spaces with inadequate ventilation or air handling within which the concentration of exhaled respiratory fluids, especially very fine droplets and aerosol particles, can build up in the air space,” the CDC emphasized.¹³

The authors of a recently published study confirmed aerosol transmission was responsible for at least some infections in an outbreak among 11 healthcare workers and eight patients. “The presence of SARS-CoV-2 in aerosols at the nurses station on ward A was temporally associated with the outbreak,” they found.¹⁴

The World Health Organization held out longer than the CDC, but finally concluded airborne transmission was occurring during the pandemic, vindicating some scientists and airflow engineering experts who had been making this point for years. Some suggested an implicit bias against determining COVID-19 was airborne because droplet precautions are less expensive and had become entrenched practice.

“We knew this during SARS-1, 20 years ago,” says Gabor Lantos, PEng, MBA, MD, president of Occupational Health Management Services in Toronto.

Dogma and Mutability

Walensky fell on her sword, casting no outward blame at those who refused to be vaccinated, and those who denied and prolonged the severity of the pandemic through misinformation. In addition to the other obstacles, the CDC faced a massive misinformation campaign about the safety of the first COVID-19 vaccines and the subsequent refusal of about 20% of the population to take the vaccine.

It is doubtful if improved messaging would have reached these people. Never have so many vials of safe and effective vaccines sat in storage while people who refused the shots filled up available hospital beds. The downstream effect is that some fully vaccinated people died in EDs waiting to be treated for some non-COVID critical illness.

Now, there are additions to the formulary, like antiviral Paxlovid, and Evusheld for pre-prophylaxis of the immune-compromised with conditions that contraindicate the regular vaccine. More treatments and vaccines are forthcoming because SARS-CoV-2 is persistent, carrying the threat of further mutation as long as it endures.

“COVID is here — we are at a point where 450 people on average are dying a day,” said Daniel Griffith, MD, an infectious disease physician at Columbia University.¹⁵ “Those are mostly unvaccinated. I know the CDC is being beaten up, but I’m not sure they should be. There is a certain reality when you have been offered all of the tools [of prevention and treatment]. At some point, you have to decide what you are going to do going forward.”

Even as the FDA moves forward with a new fall-winter booster shot — a bivalent vaccine that combines the original strain with an omicron component — approximately half of those originally vaccinated with a two-shot series have not taken the third dose booster.

As of Aug 27, the omicron subvariant BA.5 represented 88.7% of the circulating virus, with BA.4.6 at 7.5% and BA.4. at 3.6%.¹⁶ Although there have been variations of other SARS-CoV-2 strains, none have mutated into as many offshoots or “subvariants” as omicron. The FDA’s general thinking is including the most current subvariant in a fall booster shot would at least bring human immunity that much closer to however the virus is evolving. But the truth is nobody knows what version of SARS-CoV-2 will be circulating next winter.

This is the challenge the CDC faces. The agency made its full share of mistakes but faced a legion of troubles bookended by the dogmatic, false beliefs of millions of people and a virus with remarkable mutability to escape vaccines and increase transmissibility. Thus far, it has been a fatal combination.

REFERENCES

1. LaFraniere S, Weiland N. Walensky, citing botched pandemic response, calls for C.D.C. reorganization. The New York Times. Aug. 17, 2022.
2. Centers for Disease Control and Prevention. Transcript for the CDC telebriefing update on COVID-19. Feb. 26, 2020.
3. Stanley-Baker I, Sun LH. Senior CDC official who met Trump’s wrath for raising alarm about coronavirus to resign. The Washington Post. May 7, 2021.
4. Johns Hopkins University & Medicine. Coronavirus Resource Center. Aug. 29, 2022.
5. Centers for Disease Control and Prevention. Monkeypox. 2022 U.S. map & case count. Aug. 29, 2022.
6. Landen X. Only 44 percent of Americans trust what the CDC has said about COVID: Poll. Newsweek. Jan. 23, 2022.
7. National Academies of Sciences, Engineering, and Medicine. Rapid Expert Consultation on Understanding Causes of Health Care Worker Deaths Due to the COVID-19 Pandemic (December 10, 2020). Washington, DC: The National Academies Press.
8. Centers for Disease Control and Prevention. Cases and deaths among healthcare personnel. Aug. 29, 2022.
9. Centers for Disease Control and Prevention. Strategies for optimizing the supply of N95 respirators. Updated Sept. 16, 2021.
10. Dörr T, Haller S, Müller MF, et al. SARS-CoV-2 acquisition in health care workers according to cumulative patient exposure and preferred mask type. JAMA Netw Open 2022;5:e2226816.
11. National Academies of Sciences, Engineering, and Medicine. Ensuring an Effective Public Health Emergency Medical Countermeasures Enterprise. Washington, DC: The National Academies Press, 2021.
12. American Hospital Association. CDC updates COVID-19 testing guidance. Sept. 18, 2020.
13. Centers for Disease Control and Prevention. Scientific brief: SARS-CoV-2 transmission. Updated May 7, 2021.
14. Stern RA, Charness ME, Gupta K, et al. Concordance of SARS-CoV-2 RNA in aerosols from a nurses station and in nurses and patients during a hospital ward outbreak. JAMA Netw Open 2022;5:e2216176.
15. TWiV 928: Clinical update with Dr. Daniel Griffin. Aug 20, 2022.
16. Centers for Disease Control and Prevention. Variant proportions. Aug. 27, 2022.