By Gary Evans, Medical Writer
Once widely considered the greatest public health institution in the world, the Centers for Disease Control and Prevention (CDC) has conceded it mishandled the COVID-19 pandemic response and has begun an ambitious rebuild. A culture change is sought to break down silos and better communicate both in-house and to the public.
In a video message to CDC employees, agency director Rochelle Walensky, MD, said “To be frank, we are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications.”1
The move to revamp the agency comes after James Macrae, MA, MPP, of the Health Resources and Services Administration began in April to review the CDC’s pandemic response. In addition to interviewing some 120 CDC employees, Macrae talked to key external stakeholders.
McCrae’s report has not yet been published, but the CDC press office released some of the key findings and recommendations:
• Share scientific findings and data faster: Release scientific findings and data more quickly in response to the need for information and action and be transparent about the agency’s current level of understanding.
• Translate science into practical, easy-to-understand policy: Implement a standardized policy development process for implementation guidance documents that will be vetted appropriately.
• Prioritize public health communications: Prioritize and enhance public-facing health communication practices and staff expertise.
• Promote results-based partnerships: Work more effectively with public health partners to accomplish result-oriented goals, and work to address the limitations of a siloed approach to solving major public health problems.
• Develop a workforce prepared for future emergencies: Strengthen the CDC workforce in responding to infectious and noninfectious public health emergencies, including new skills, training, and capabilities, and aligning incentives for commitment to these efforts.
Failure Has Many Fathers
Walensky drew praise for both ordering the review and the unvarnished acceptance of responsibility. Although the CDC made multiple mistakes, there were many other contributing factors to a failed national response that has resulted in more than 1 million American deaths — by far the most in any country.
“Failures extended beyond the CDC,” says Linda Dickey, immediate past president of the Association for Professionals in Infection Control and Epidemiology (APIC). These included “supply chain failures, misinformation regarding masking and vaccines, lack of standards and interoperability for gathering critical public health data, and the need to invest in infection prevention and control infrastructure and personnel to support surge capacity during a pandemic,” she says.
The CDC is embracing the recommendations and will try to become a nimbler agency, Walensky said. To do so, the CDC will have to overcome communications breakdowns and release data to inform action at a more rapid pace.
“Data access is a profound problem,” says William Schaffner, MD, a CDC advisor and medical professor at Vanderbilt University. “Data are the foundation on which public health programs are built and public health recommendations are made. If the data stream is late or incomplete, that impedes a national response.”
Others caution not to sacrifice appropriate peer review of data in the name of shorter timelines.
“I am concerned about the idea that the CDC would de-emphasize academic research and publish more quick communications,” says Monica Gandhi, MD, MPH, professor of medicine at the University of California San Francisco. “Any data with policy implications should be rigorously peer reviewed. So, part of this overhaul should be making data easily accessible to academicians and other researchers for rigorous peer review.”
During the pandemic, articles awaiting peer review have been published with that absence of feedback and oversight duly noted, but inordinate delays of CDC recommendations are another matter.
“Peer review is important, but we cannot let it delay communications,” Schaffner says. “There has been a certain tolerance of the passage of time so that many people can peer review and comment on proposed recommendations and communications from the CDC before they are released. That won’t work in the 21st century with a 24-hour news cycle.”
A Fractured System
Part of the pandemic response problem is that much of public health authority defers to individual states, creating a somewhat fractured system that hinders a unified national response, he adds. This also is part of the “interoperability” problem Dickey mentioned, since data detail may vary by state.
For example, it was clear early in the pandemic that there was no standardized system to report morbidity and mortality in healthcare workers. The CDC has redoubled efforts in this area, but still must extrapolate to some degree from various state reporting systems. COVID-19 may not be listed as the cause of death or the occupation of the deceased may not be recorded. As of Aug. 24, 2022 — in what are no doubt underestimates, the CDC said of the confirmed 967,711 cases of COVID-19 in healthcare workers, death status is available for 538,898 (56%). Of those, 2,344 died.2
In a move viewed by some as a pandemic response that had become politically charged, 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 that “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.”3
In a particularly unfortunate development, the measure of wearing a face mask during a respiratory pandemic became a kind of political statement, dividing people along partisan lines.
“There isn’t any doubt that public health is frequently political health,” Schaffner says. “You can’t separate the two, and if the political structure does not value and support public health, that will result in confusion and an inadequate response. That’s what happened. We really did not have a national response. It was left to the states, and we had a hodgepodge.”
Keep it Simple
Walensky took the CDC helm from Robert Redfield, MD, in January 2021, but the pattern of mistakes and missteps continued on her watch under the Biden Administration. Communications issues dogged the director, with news reports at one point underscoring she needed training in dealing with the media and was being tripped up in aggressive interviews.4
Written communications on the pandemic fared little better and too often were considered arcane and confusing. To some extent, this criticism preceded the pandemic.
“I like to joke that I’m the president of the CDC fan club,” Schaffner says. “But for years, many of us have thought that communications from the CDC were not couched in terms that were immediately and easily understood — not only by public health authorities, but certainly the general public.”
Going forward, communicating clearly in a timely fashion will be a daunting challenge for the CDC.
“Public health communications have to be science-based and simple,” he says. “If you make it complex, you raise questions and cause confusion. This is one of the very difficult cultural problems for the CDC. They wish to be very epidemiologically precise, but that sometimes results in complexity and consequent confusion. You can’t paint with a very small brush. You’ve got to get out a big brush — the kind you would use to paint the side of a barn.”
As the mistakes and miscommunications continued in a politicized pandemic, public faith in the CDC steadily eroded.
“Trust in the CDC has fallen during the pandemic,” Gandhi says.
Still, the agency’s admission of errors and commitment to transformation actually 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,” she 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.”
Indeed, Walensky’s assessment of the CDC’s poor performance sets a solid, sincere tone for the agency’s reinvention.
“I think [she] displayed great leadership and courage in ordering this full evaluation of the 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,” he said. “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.”
That said, overall, the CDC’s pandemic response has been weak, and the agency has underperformed in multiple arenas, he said.
“Above all, the 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, he adds.
Test, PPE Shortage
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. The CDC typically 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.
Many healthcare worker infections and deaths occurred in the context of 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 in caring for COVID-19 patients, with N95 masks reserved for aerosol-generating procedures.5 A recently published study comparing surgical masks to N95 respirators over cumulative exposure times found that “the odds of being SARS-CoV-2-positive were reduced by more than 40% in individuals using respirators irrespective of cumulative exposure.”6
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 produced rapidly and distributed by manufacturers. Neither proved to be true. There were some N95s in the SNS, but not nearly enough as demand increased dramatically over a short period of time.
When the pandemic hit, the SNS had not been formally assessed in years, although it is supposed to be inspected annually, according to an after-action report by the National Academy of Sciences.7 The CDC does not take full blame for this one, although they scarcely can distance themselves, since they are one of several federal agencies that comprise the U.S. 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 states. “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. Remarkably, the shortage of N95s was not declared over until Aug. 26, 2022, about two years and seven months after the first laboratory-confirmed cases of COVID-19 in the United States.
“Demand for this type of face protection device commonly used in healthcare settings no longer exceeds the supply,” the Food and Drug Administration (FDA) announced.8 “This action is the result of increased domestic manufacturing of N95 respirators, as well as updates to the FDA’s supply chain assessment based on engagement with industry and federal stakeholders, and the CDC’s National Institute for Occupational Safety and Health’s approval of new disposable N95s and reusable respirators.”
Mask Reversal
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, the CDC seemed to some critics to be suggesting the pandemic was over. Some warned it would cause confusion, noncompliance, and a possible spike in cases.
Indeed, an outbreak of the Delta variant in Provincetown, MA, a couple of months later showed that 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 essentially was an irreversible error, as many people never went back to masking. Pandemic fatigue has only deepened since then, although the Omicron variants currently circulating also can cause breakthrough infections in the vaccinated.
In admitting the CDC’s mistakes, Walensky cast no outward blame at those who refused to be vaccinated or 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 be even partially immunized.
It’s 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 of this is that some fully vaccinated people died in emergency rooms waiting to be treated for non-COVID critical illnesses.
REFERENCES
- LaFraniere S, Weiland N. Walensky, citing botched pandemic response, calls for C.D.C. reorganization. The New York Times. Published Aug. 17, 2022. https://www.nytimes.com/2022/08/17/us/politics/cdc-rochelle-walensky-covid.html
- Centers for Disease Control and Prevention. COVID Data Tracker. Cases & deaths among healthcare personnel. Aug. 24, 2021. https://covid.cdc.gov/covid-data-tracker/#health-care-personnel
- American Hospital Association. CDC updates COVID-19 testing guidance. Published Sept. 18, 2020. https://www.aha.org/news/headline/2020-09-18-cdc-updates-covid-19-testing-guidance
- Blake A. Rochelle Walensky is not good at this. The Washington Post. Published Jan. 10, 2022. https://www.washingtonpost.com/politics/2022/01/10/rochelle-walensky-is-not-good-this/
- Centers for Disease Control and Prevention. Strategies for optimizing the supply of N95 respirators. Updated Sept. 16, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html
- 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.
- National Academies of Sciences, Engineering, and Medicine. Ensuring an Effective Public Health Emergency Medical Countermeasures Enterprise. The National Academies Press; 2021. https://doi.org/10.17226/26373
- U.S. Food and Drug Administration. FDA removes N95 respirators from medical device shortage list, signaling sufficient supply. Published Aug. 26, 2022. https://www.fda.gov/news-events/press-announcements/fda-removes-n95-respirators-medical-device-shortage-list-signaling-sufficient-supply
Once widely considered the greatest public health institution in the world, the Centers for Disease Control and Prevention has admitted it mishandled the COVID-19 pandemic response and has begun an ambitious rebuild.
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