Ode to the CDC

By: Foss Tighe
April 28, 2020

It was probably during the Ebola outbreak in 2000 or 2002 when I remember hearing news reports that “epidemiologists from the Center for Disease Control in Atlanta Georgia were heading to Africa to help fight the Ebola virus…”. My heart swelled with pride and my spine tingled.

Founding in the 1946, the Center for Disease Control (CDC) has had as its mission:

CDC increases the health security of our nation. As the nation’s health protection agency, CDC saves lives and protects people from health threats. To accomplish our mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these arise.

CDC’s Mission – https://www.cdc.gov/about/organization/cio.htm

During my career as a public health researcher with a Masters in Public Health the CDC represented to me all that was good about government. It worked at the intersection of science, health research and first responder to public health emergencies. Not only did CDC work at this vital intersection of critical functions, in many ways the CDC was the physical manifestation of those intersecting functions. When there were dangerous infectious disease outbreaks anywhere in the world, the definitive diagnosis would come from laboratories at CDC based on specimens collected in remote locations and flown to Atlanta.

Like John F Kennedy boulevards around the world, many nations have emulated the United States by naming their disease prevention agencies as their CDC. These countries include Taiwan, China, India, Australia, Nigeria, Latvia and Kenya.

My wife works in health care and is also trained in public health. She has often mused about what life would have been like had she pursued a career at the CDC. Children often function as petri dishes for parental admirations and aspirations. When we were searching for a big reward for our oldest daughter, we asked her what she would like. Somewhat embarrassed, she asked if it was possible to get a tour of the CDC. For her 18th birthday she asked for a print subscription to the CDC’s premier publication, Morbidity and Mortality Weekly Report (MMWR). Its available on-line for free, but she really wanted to have a physical copy. We obliged on MMWR, but the tour of CDC has yet to happen.

With my lofty feelings toward the CDC, it has been a crushing experience to realize that in our country’s hour of need, the CDC failed us catastrophically.

When the Wuhan outbreak first appeared in the news and the early reports about the novel coronavirus included information about it’s highly infectious nature, and it’s case fatality rate, alarms must have gone off at CDC. Anyone with the most basic training in Epidemiology, and there are hundreds, perhaps thousands, of epidemiologists at CDC, could have done back of a napkin calculations to show that if left un-checked the virus had to potential to kill millions of people in the United States.

The President likes to brag about his early, January 31, decision to block flights from China. But real prevention needed to start much earlier. The CDC, in Taiwan, was having public health officials board flights arriving from Wuhan on the last days of December 2019 looking for passengers with fevers and symptoms of pneumonia. Taiwan’s government based on monitoring of social media in Wuhan, had detected a new infectious disease threat even before we had the name “novel coronavirus”. The CDC in Taiwan, would go on to spearhead the most effective coronavirus containment in the world despite their proximity to the original epi-center and early cases of the disease.

CDC EIS Recruitment Graphis

The CDC practically wrote the book on infectious disease prevention. It’s Epidemic Intelligence Service (EIS) is a model for deploying epidemiologist led multi-disciplinary teams into infection disease hot spots.


Sentinel Surveillance:

Sentinel Surveillance is one of the most basic tools in the EIS play book. On February 13, Health and Human Services Secretary Alex Azar announced that CDC would start sentinel surveillance programs for the coronavirus is 5 cities in the United States. Sentinel Surveillance is the idea where you set up testing in multiple locations to act as an early warning system for infection. This is a tool you use, ideally before the infection arrives. This system was to be set up piggy backed on CDC’s annual flu surveillance system, which monitors people with influenza like illness (ILI). This is the system that would tell us when and if the coronavirus community transmission started.

However, the first location, Chicago, did not start testing until March 2. For comparison, by February 23, my wife and I, just by following the news, had already decided that community transmission was very likely under way, and we had already stockpiled toilet paper and canned goods.

Stockpile of supplies for impending coronavirus outbreak in United States. Tonic water (gin & limes) included as a, mostly, humorous nod to early research that Malaria medications might be protective against coronavirus.

The Chicago sentinel surveillance site detected positive cases during their second week of operation. The two other sentinel surveillance sites that eventually got started, Los Angeles, and Cook Country Washington, already had 10’s or 100’s or cases detected in their areas before their “early detection” system was launched.

Effective Sentinel Surveillance in the United States should have been in place in early January.

Testing:

Of course a huge portion of the CDC’s failure to defend the country from the coronavirus stems from early mis-steps in testing. I know its Monday morning quarter-backing, but it seems with millions of lives potentially in the balance we should not have put all our eggs in one basket. In War you don’t count on the development of only one weapon system. During WWII the United States continued to build air-craft carriers even while research on the Atomic Bomb moved forward. It would have been prudent to have one CDC lab staff work with the WHO supplied testing kits, while a second lab worked on a US developed test. Short of doing that, when the US developed kits become problematic, a backup lab team should have started working with the WHO kit. Or we should have realized that we are no longer the only country in the world capable of innovation, we should have gone with our tails between our legs and asked for help from South Korea, Singapore, Germany or Taiwan.

There is no explanation beyond hubris for not seeking help outside the U.S. when we first detected problems with the U.S. developed test.

Contact Tracing:

Suddenly everyone in the United States is talking about Contact Tracing to contain the virus. Early case detection, contact tracing, isolation and quarantine are also pages right out the of the CDC’s EIS tool kit for control of infectious disease outbreak. Why was that not an early focus of the CDC and Federal response. Of course state and country public health departments have protocols for this and they were utilized. However, an outbreak of this scale required far more resources than state and county public health departments had on hand. The CDC should have been urging the inclusion of extensive funding for Contact Tracing in the early days of the outbreak. Though testing can make such programs far more effective, lacking good tests we should have fallen back on isolation and contact tracing of presumptive infections.

Months have now passed, hundreds of thousands of cases have been detected, the economy is in shatters, and we have allocated billions to supporting things like the airline industry. But while we await a vaccine, Contact Tracing is only now coming into focus as something we should do.

Each member of a CDC EIS team is equipped with a laptop that, among other things, contains software designed to manage contact tracing. These EIS teams will travel the world, insisting that governments in hot spots immediately implement aggressive contact tracing and isolation. Why wasn’t the CDC telling the U.S. the same advice when we needed it?

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