How the CDC's handling of COVID-19 impacted American public health

Rear Adm. Timothy Ziemer, a top official on the National Security Council for U.S. pandemic response, left the Trump administration early May 2018, and members of his team were reassigned. Though NSC spokesman Robert Palladino said the administration was committed to global health, they did not replace Ziemer, meaning there was no top-level global health security official after the exit.

Although the CDC was granted a $7.3 billion budget in 2019—$2.5 to $3 billion of which was for infectious disease—the majority was “earmarked for existing pathogens,” per Michelle Minton of Inside Sources, leaving the organization vastly underprepared and underfunded for the current pandemic. The $855 million for “public health preparedness and response programs,” was “mostly a conduit for transferring federal funds...to state agencies during emergencies like natural disasters,” and that of the $600 million for emerging and zoonotic infectious diseases, “only $185 million went toward the emerging type—like COVID-19.”

In January 2020, still two months from the WHO’s “pandemic” designation, the CDC said in a press release that “the risk from 2019-nCoV to the American public is currently deemed to be low.” In an early precautionary measure taken jointly along with the Department of Homeland Security’s Customs and Border Patrol, three U.S. airports (JFK, LAX, SFO) began health screenings of travelers from Wuhan.

That same day, the CDC held its first COVID-19 telebriefing. In the nascent stages of what they called an “outbreak of pneumonia in Wuhan,” the CDC explained the “large family of viruses” known as coronavirus and that the first related respiratory illness had been reported Dec. 30, 2019. They referenced past action with MERS and SARS, though the word “pandemic” was never used.

Only four days after the briefing—and 10 days after China's first death—a man in his 30s became the first U.S. case after he returned to Washington state from Wuhan. At this time, nearly 300 people in Asia had tested positive for the disease, including early cases in Japan, South Korea, and Thailand.

The White House finally took action, forming the President’s Coronavirus Task Force. Per a release, it planned to “lead the Administration’s efforts to monitor, contain, and mitigate the spread of the virus, while ensuring that the American people have the most accurate and up-to-date health and travel information.”

Curiously leaving out any CDC members save for director Dr. Robert Redfield, the task force was helmed by Department of Health and Human Services Secretary Alex Azar and introduced Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, into the public consciousness.

According to a March BBC report, “The US declined to use a test approved by the World Health Organization in January—instead, the CDC developed its own coronavirus test.” As a consequence of manufacturing defects in these CDC tests, moreover, “many of the results were inconclusive.”

In April, a federal investigation confirmed the faulty CDC tests had been contaminated with the coronavirus itself, making it impossible for them to determine the status of a sample.

Essential weeks were lost early in the spread of COVID-19 in the U.S. because, in creating its own test that was faulty, the test didn’t work in the vast majority of labs. That meant a delay from the beginning to the end of February whereby only a handful of labs (where the tests were working properly) could use tests while the virus spread unchecked throughout the United States.

The first CDC test kits were sent out to state and local government labs. Similar facilities at many universities and private companies prepared their equipment and staff to process COVID-19 tests, but they did not receive the necessary supplies or permissions until weeks later. Restricting the test kits to public labs caused further delays in building a widespread testing system.

From January to March, the CDC had a chronic organizational issue that included losing multiple forms from agencies reporting on COVID-19 cases. In a Feb. 13 email, a CDC worker characterized job openings as an "URGENT" needs; those jobs included "Identifying missing PUI [persons under investigation] forms for follow up and contacting states to resend missing forms—this is an ongoing issue for new and past PUIs."

The CDC on Feb. 22 rolled out narrow guidelines for who was eligible for COVID-19 tests. These test criteria, originally presented Feb. 19 in a presentation to state officials, included a person who had direct contact with an infected individual, or someone who had recently returned from China, even though the virus had landed in the U.S. a full month earlier.

The CDC already had a data portal, called DCIPHER, in use to track national outbreaks when COVID-19 hit. On Feb. 19, the public health agency presented on this system to states, but state officials were not fully trained on using it until the week of Feb. 24. Incidentally, it was the same week the country had its first officially recorded case of COVID-19 transmission by community spread.

On Feb. 26, the U.S. reported the first COVID-19 case in someone without the relevant travel history or explicit exposure. Representing just the 15th U.S. case, the CDC believed it was the first to occur via community spread. According to research by epidemiologist and Nextstrain founder Trevor Bedford, however, the virus had likely already been spreading person-to-person through communities in Washington state and beyond since January.

Most indicative of the domestic failure in urgency and capacity, by Feb. 26, the CDC had tested less than 500 people. The American public-health labs—aka non-CDC labs—had collected a minuscule 102 specimens by Feb. 26—or tests for about 50 people, per The Atlantic’s Alexis Madrigal and Robinson Meyer.

It had been a full five weeks since the first positive case in the U.S. was recorded.

The CDC formally ramped up testing efforts on Feb. 29, allowing academic hospitals to develop and use their own tests. Other academic and commercial labs followed suit. But even with this increased manpower, crucial supplies such as swabs used to collect samples and chemicals used to isolate genetic material were in short supply, and other logistical obstacles held up labs through the next month.

On April 9, Amy Maxmen reported for Nature Communications that thousands of COVID-19 tests were languishing in labs unused due to administrative and communication breakdowns, such as university labs not having compatible health records software with nearby hospitals.

In February, when the U.S. began testing for COVID-19 on a national scale, data on test results as well as on the sheer number of tests being conducted went through two different pipelines. The public labs (and, later in the testing cycle, private labs) testing patients for COVID-19 sent their data to state health departments, which began reporting the figures on individual sites, and to a national system run by the Department of Health and Human Services (HHS).

The national data were used for internal planning by the HHS and the CDC, but would not be publicly available until May—plenty of time for data processes and standards between the federal government and individual state health departments to diverge.

ProPublica reported that a CDC officer at LAX on Feb. 29 emailed a colleague stating private flights were not being screened. A couple of hours later, the officer emailed again to say “And, maybe, just kidding,” referring to disparate information from CDC headquarters about screening incoming flights.

During a Feb. 29 White House briefing, CDC Director Robert Redfield said the risk of COVID-19 transmission was low; and that Americans ought to “go on with their normal lives.” That same day, the first U.S. death from COVID-19 was reported. Later, officials learned of COVID-19-related deaths earlier in February.

Per Rolling Stone reporting on May 10, Imperial College research from London found as many as 90% of all deaths from COVID-19 might have been avoided if shutdowns in the U.S. started by March 2.

It was March 3 before the CDC changed its COVID-19 testing guidelines. Updates expanded the scope of who could be tested by removing access barriers such as travel history that included an area with an outbreak, contact with someone who tested positive for COVID-19, or contact with someone exhibiting significant symptoms.

Although the CDC has collected data on the number of COVID-19 tests conducted in the U.S. since the start of the outbreak, when states increased their testing efforts in early March, the CDC stopped publishing a count of the total tests conducted nationwide. To fill this information gap, Robinson Meyer and Alexis Madrigal of The Atlantic surveyed state health departments and found that 1,895 people had been tested as of March 6. They reported over 200 positive COVID-19 cases as of that same day, while the official CDC tally listed 99 cases.

"Testing is the first and most important tool in understanding the epidemiology of a disease outbreak," Meyer and Madrigal wrote. This article helped inspire the COVID Tracking Project, a volunteer effort housed at The Atlantic, which compiles and standardizes COVID-19 data from state health departments; in lieu of the CDC publishing these data, the COVID Tracking Project would become America's primary source for COVID-19 testing numbers through March and April.

The CDC’s regular media telebriefs on COVID-19 that began on Jan. 17 ended on March 13 without explanation. CDC’s lack of direct communication to the public has raised red flags with public health experts: Tom Inglesby, director of the Johns Hopkins Center for Health Security, told NPR the fact that the CDC is not participating in public briefings is a departure from how the nation’s public health agency has always dealt with epidemics in the past.

Former CDC director Tom Frieden said, “Fighting this pandemic without CDC central to that fight is like fighting it with one hand tied behind your back," reported NPR.

Editor's note: On May 30, the CDC announced that it would restart regular COVID-19 briefings as the death toll from the virus reached more than 103,000. 

As the CDC continued to not publish a count of how many Americans had been tested for COVID-19, the responsibility for reporting this crucial public health metric was left on the shoulders of state health departments, each of which operated under its own data standards.

Some states published only their counts of positive cases; others published counts of total tests conducted or tests that yielded a negative result. Some states published counts of their citizens who were hospitalized due to COVID-19; others did not. Some states updated their counts every day; others updated less frequently. Some states reported their total tests in a unit of people tested; others reported in a unit of specimens tested (including duplicates for people who were tested more than once). All of these data differences have made it difficult for public health officials at both the local and national levels to determine the scale of outbreaks in different areas, allocate resources, and predict potential outcomes.

The CDC’s large-event guidelines included a list of considerations that might warrant postponement or cancellation, such as the number of guests and whether elderly people or other at-risk groups will be in attendance. If attendees were considered healthy and of a non-risk age, the CDC recommended capping such events at 250 people. On the same day, the total number of cases in the U.S. passed 5,000, according to historical data from the COVID Tracking Project.

As testing demand increased across the country in March, private biotech companies sought to fill the gap left by government public health departments. As of May 28, the FDA has approved 82 diagnostic tests that can be used to test for COVID-19. One recent addition is an at-home test kit by the health company Everlywell, approved on May 15.

In the early months of the U.S.'s outbreak, public health officials, including CDC leaders, advised Americans against wearing masks unless they experienced COVID-19 symptoms or worked in health care settings. Masks were limited, officials explained, and should be conserved for people who needed them, especially as strained supply chains and high numbers of patients in COVID-19 hot spots such as New York City caused masks to go in short supply for health care workers for those locations. However, conflicting information from different sources and growing evidence that the coronavirus can spread through the air caused widespread confusion about who should wear a mask and why.

While formal counts of deaths due to COVID-19 passed 1,000 at the end of March, this figure only reflects the deaths of Americans who have tested positive for the coronavirus. Many public health researchers estimate that the true cost of this outbreak may be much higher, as thousands of Americans may have passed away without receiving a test or failed to receive medical attention for a different condition as health care systems have been overburdened.

According to estimates from the New York Times, about 16,000 deaths in the U.S. went unattributed from March 15 to April 25; while many of these deaths may be unrelated to COVID-19, the figure provides a sense of scale for the true toll.

By the end of March, New York City had become a clear epicenter for America’s COVID-19 outbreak. On March 28, the day that the CDC advised residents of New York, New Jersey, and Connecticut to avoid domestic travel for two weeks, the state of New York had a total of about 52,000 cases and over 700 deaths due to COVID-19, according to historical data from the COVID Tracking Project. China placed 15 cities under full or partial lockdown in late January, when under 3,000 cases were confirmed across the country.

As COVID-19 continued to spread through the U.S., public health researchers saw mounting evidence that people infected with the coronavirus could spread it to others even if they showed no symptoms of the disease. Due to the danger of asymptomatic spread, the CDC issued a recommendation on April 3 guiding Americans to wear masks in public settings, even if they have not tested positive for COVID-19 or experienced any symptoms. The CDC recommends that members of the public wear reusable cloth masks, in order to reserve surgical masks and N-95 respirators for health care workers and other frontline workers.

Tagged “COVIDView,” the CDC’s weekly surveillance report was created to present and explain information about COVID-19. This information included everything from lab data to emergency department visits. In the first week, COVIDView highlighted data on visits to doctors and emergency rooms for symptoms that are similar to those associated with COVID-19.

Visits to outpatient providers and emergency departments for illnesses with symptom presentation similar to COVID-19 are elevated compared to what is normally seen at this time of year. At this time, there is little influenza (flu) virus circulation.

"Since the beginning of the Covid-19 pandemic, the CDC has been inexplicably absent, and Americans are suffering and dying for it," wrote Dr. Ashish K. Jha, the director of the Harvard Global Health Institute, in a STAT News essay that reflects the views of many other public health scientists and officials. Jha argued that, while the CDC has long provided local health departments with guidance and standards, which enabled national research on different diseases and conditions impacting the nation, during the COVID-19 pandemic, the agency has failed in its duty. He pointed out issues with CDC-led testing and data reporting, as well as a lack of evidence-based guidance in the agency's decisions.

The CDC Prevention team was told its report offering reopening guidance for local and state officials, business owners, faith leaders, and educators “would never see the light of day,” according to an anonymous CDC official who spoke to the Associated Press. On May 7 when White House coronavirus adviser Dr. Deborah Birx was asked about the report, which was supposed to be published May 1, she told CNN it was still being edited and that “it was more about simplification.” The AP received a copy of the 17-page report from a federal official who did not have the authorization to release it.

On May 8, the CDC published a national data dashboard, including total counts of COVID-19 cases, tests conducted, and deaths in every U.S. state—finally making available the crucial data the agency had failed to publish since the end of February. The data on this dashboard are aggregated from public and private labs, but, in many states, they differ significantly from data reported directly by state health departments.

As of May 18, according to a report by the COVID Tracking Project, the CDC’s total test counts were over 200,000 higher in Florida than Florida’s count, and over 150,000 lower in California than California’s official count. Such discrepancies are likely connected to differences in data standards and reporting methods that call the CDC’s authority into question.

The CDC’s official counts of COVID-19 tests are combining counts of two different types of tests, reported Alexis Madrigal and Robinson Meyer of The Atlantic on May 21. Viral tests, or polymerase chain reaction (PCR) tests, use genetic sequencing to determine who is infected with the coronavirus at a particular point in time; these tests are used to track outbreaks in real-time. Antibody tests, on the other hand, measure the immune system’s response to infection; these tests are used to determine the overall scale of infection in a community.

With this decision to combine results of these two different tests in one metric, the CDC has made its data impossible for public health experts to interpret and has falsely amplified the nation’s test positivity rate—basically, making it look like we’ve curbed our nation’s outbreak more than we actually have. Several states, such as Texas and Virginia, have separated out their counts of viral and antibody tests since The Atlantic and other publications called attention to this vital error. But, as of May 29, the CDC is still conflating these results.

In response to a congressional request for data on how the novel coronavirus has impacted communities of color, the CDC released a four-page report congressional leaders blasted as incomplete. The report, released on the deadline set by Congress, included multiple links back to CDC’s public website. One such link was to hospitalization data by race and ethnicity; however, the data included only came from a particular network of hospitals from 14 states—leaving 90% of the American population out.

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