Monday, April 20, 2020

What Happened to the CDC?

Last week, Tom Frieden, the former Director of the US Centers for Disease Control in the Obama administration, wrote an editorial in the New York Times. In his article, he praised the professional staff at the CDC emphasizing their scientific acumen, skill, experience and expertise. I have come to know many scientists at the CDC to one extent or another over the last 40 years and I agree with Dr. Frieden’s assessment.  At the same time, Dr. Frieden points out that the CDC has to do better in our current pandemic. That must be the understatement of the century. 

The botched CDC attempt at providing testing for public health labs around the US was clearly a major roadblock to establishing the kind of robust testing we would have needed early in the US outbreak.  As I noted in a previous blog, what we needed to do at the beginning was to identify infected individuals, get them quarantined and then identify all their contacts, test them and quarantine them as necessary. By the time we had any sort of access to widespread testing, limited as it has been, it was too late to carry out this basic outbreak control measure and we were stuck with our current situation – everyone and everything locked down.  This critical misstep may have led to the fact that the CDC has been shunted aside. 

Dr. Frieden says that the CDC website is the best place to get information and guidance on the outbreak. I respectfully disagree. I look at the CDC coronavirus websites every day.  Compared to the John Hopkins siteworldometer, and others, I’m ashamed at the lack of utility of the CDC site for understanding the current covid-19 epidemiology in the US. 

Recently the CDC released guidance for allowing employees at essential businesses to work follow an exposure to a known covid-19-infected individual. This guidance suggests that as long as the individual is asymptomatic, it is OK for them to be at work. But this guidance flies in the face of clear evidence suggesting that pre-symptomatic or asymptomatic individuals are responsible for up to 25-30% of covid-19 transmission to others. I queried the CDC as to the scientific basis for this recommendation.  They responded without actually providing the kind of scientific data I requested. They do recommend that workers be screened for fever and that they maintain a distance of 6 feet from others . . . .

Currently, the CDC is relying on death certificates (with many caveats) to tabulate coronavirus mortality. But they know that this is entirely unreliable. We will probably have to resort to a statistical approach looking at excess deaths be geographic area, age and other variables to estimate covid-19 mortality rates. Where is the CDC leadership on approaches like that? (In fairness - they say they are working on it). 

Dr. Frieden is again correct when he says that the CDC has the expertise to validate the various tests we need to be using including the current ones used to identify infected patients and the antibody tests we need to determine who has already been infected and who might be immune to the virus. Where are these analyses – especially of the many antibody tests that are currently on the market in the US without having been formally validated by FDA? 

He notes that the CDC does have funds to distribute to public health facilities around the country. But this funding is woefully inadequate and has been decimated by successive administrations and congresses for years.  

To open the country up to anything resembling normal activity, we still have to be able to go back to our basic outbreak control measures of case finding and contact tracing. Even with access to testing way beyond what is currently available (based on lack of reagents and swabs), we will still need an army of contact tracers.  The requirement for tracers could be reduced by using smartphone technology as was done successfully by South Korea, Taiwan and Singapore to name a few. Those countries also enlisted police and army reserves to help with contact tracing. Massachussetts and California are gearing up for this task with or without smartphone technology. But, in my view, the CDC should be leading the charge here.  Where are they?

I have wracked my brains trying to understand what could have happened to the professionals at CDC. One example might be Dr. Nancy Messonnier who tried to warn Americans of the coming epidemic at the end of February. We have hardly heard from her since. I’m tempted to speculate that the CDC, similar to what happened at FDA a number of years ago, came under severe political pressure with the result that career scientists are keeping their heads down. If so, I find this to be incredibly unfortunate since the CDC is one place where we have the expertise we need to face this epidemic.  It just seems like the CDC experts have been missing in action.  

While I recognize CDC’s missteps in handling this epidemic, I also understand that the CDC could still provide critically important leadership in getting us out of this mess. I miss the CDC I used to know. 

In a future blog, I’ll discuss my thoughts on how we get back to some semblance of normality. 



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