WASHINGTON — Nearly a year ago, amid concerns about how to prevent transmission of the virus causing Covid-19, scientists were beginning to conclude that rigorous disinfection of surfaces — say, fogging them or deep-cleaning with bleach — was overkill.
Academics were warning that the risk of so-called fomite transmission was wildly overblown. In the fall, research from Israel and Italy found that the virus couldn’t even be cultured from surfaces in hospital infectious disease units. By February of this year, the editorial board of Nature was openly urging the Centers for Disease Control and Prevention to update its guidelines.
The CDC did so — last month.
That so much time passed before the nation’s leading public health agency took a stand on an issue that seemed patently obvious to others was puzzling. But it was hardly an isolated incident.
After months of pleas from scientists, the CDC acknowledged last week that Covid-19 can be spread through small particles floating in the air — an acknowledgment that came more than a year after some experts began warning that the virus is airborne. Separately, it took three months after Covid-19 vaccines began going into arms before the CDC issued its first attempt at outlining the activities vaccinated people could safely undertake.
When the CDC issued new guidelines recently on when people still need to wear masks, the guidelines were seen as so conservative that they prompted a primetime rant on “The Daily Show.”
“I know science is difficult … but who’s running messaging at the CDC?” asked the show’s host, Trevor Noah.
Some public health experts are asking the same question. Most experts interviewed for this story say the agency has struggled to take advantage of the latest scientific findings to communicate as rapidly as possible with the American public. And when the guidance is issued, it tends to be overly cautious.
The explanation does not seem to be, as it might have been under the Trump administration, political interference. Rather, “there is a certain mentality when it comes to [caution] that I believe has been detrimental,” said Leana Wen, an emergency physician and visiting professor of health policy at George Washington University.
Even defenders of the CDC’s approach admitted that the agency has been conservative, and at times slow.
“I admit it is a conservative approach, and they have historically always been very conservative,” said Georges Benjamin, executive director of the American Public Health Association, who largely defended the CDC and insisted that the agency has followed the science.
The CDC did not respond to a request for comment.
The issues facing the CDC aren’t altogether new. Two former CDC directors, Tom Frieden and Rich Besser, both acknowledged to STAT that the CDC has continually labored to quickly release guidance — though, like Benjamin, defended the agency.
“In every public health crisis the complaint is made that the CDC is too slow to make recommendations,” said Besser, who served as the acting CDC director in 2009. “It’s an issue that the CDC has always grappled with and will continue to grapple with.”
Still, public health officials say the conservative nature of the agency’s approach to Covid is a marked departure from how it deals with other major public health issues, like HIV and opioid use disorder.
There, public health officials by and large embrace harm reduction: giving honest advice on how to make risky behaviors safer, rather than discouraging activities altogether. For injection drug use, that means supporting needle exchanges and providing advice on cleaning syringes; for STDs, it means making sure those at outsized risk, like sex workers, have easy access to condoms.
When it comes to Covid-19, the CDC has often stressed simply avoiding certain activities.
“There’s still a lot of abstinence-only in their Covid guidances,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. “People somehow kind of walled off what they know about HIV, opioid use, and hep C … and we are the worse for it.”
Nowhere is the CDC’s “abstinence-only approach” clearer than in its advice on travel.
The evidence has been overwhelming for months: Americans, despite possible risks to themselves and their loved ones, are traveling during Covid-19.
Some 6.8 million Americans traveled via plane around Thanksgiving. The day before Christmas Eve was the busiest day at airports since the start of the pandemic. And by March, airports around the country were regularly serving 1 million travelers daily.
But the CDC repeatedly insisted Americans should not travel. It even discouraged vaccinated people from traveling in March guidance in which it laid out what vaccinated people can and cannot safely do.
It wasn’t until April 2 that the CDC changed its stance — sort of. The agency issued guidance that day saying “fully vaccinated people can travel at low risk to themselves.” But CDC Director Rochelle Walensky contradicted the guidelines almost immediately. During a press conference, Walensky said that she continues to “advocate against general travel overall.”
“In every public health crisis the complaint is made that the CDC is too slow to make recommendations. … It’s an issue that the CDC has always grappled with and will continue to grapple with.”
Rich Besser, former acting CDC director
Other CDC guidelines have been panned as unnecessarily restrictive.
The CDC’s new guidance on reopening summer camps, for example, recommends that everyone at a camp, including children older than 2 and fully vaccinated adults, wear masks at all times — even outdoors — except when swimming or eating.
The guidance seemed disconnected from the science, which has continually shown that the risk of catching Covid-19 outdoors is low compared to the risk of indoor transmission. It’s also thought that children — particularly young children — transmit the virus less efficiently than adults, though researchers are still studying Covid-19 dynamics in kids.
Former FDA Commissioner Scott Gottlieb called the guidance “byzantine.” Libertarian publications are equating it with the government recommending “that summer camps treat kids like prisoners.” Even Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, acknowledged last week that the guidelines “certainly are conservative” and “a bit strict.”
The CDC has faced similar criticism over its recent guidelines on when vaccinated and unvaccinated people need to wear masks.
That guidance recommends that vaccinated people continue to wear masks at crowded outdoor events, and at nearly all types of indoor gatherings. The unvaccinated are urged to wear a mask in nearly every situation, except when taking a walk outdoors or at a small gathering with fully vaccinated people.
Experts, like Emory University’s Carlos del Rio, have criticized the guidance as too timid, and everyone from talk show hosts, like Noah of “The Daily Show,” to public health experts, like Virginia Tech’s Linsey Marr, have complained that the guidance, with a color-coded chart attempting to explain when to wear a mask, is too confusing. Even those who vociferously defended the CDC in interviews with STAT admitted that the CDC’s masking guidelines could have been clearer.
“They were going in the right direction,” said Howard Koh, who served as assistant secretary for health during the Obama administration. “I expect that future versions of those graphics and recommendations will be simplified and updated sooner rather than later.”
Public health officials worry that the CDC is making it harder to beat back the Covid-19 pandemic by issuing guidance that is so timid, and doing it slowly.
Multiple experts told STAT that they fear the CDC’s recommendations are becoming irrelevant for most Americans. They worry, too, that guidelines, like the CDC’s advice on masking, so seriously underplay the benefits of getting vaccinated that they risk dissuading people from getting a shot in the first place.
“It looks like there’s still confusion, and what people are wanting from the CDC … is more certainty,” said Glen Nowak, a 14-year veteran of the CDC’s communications department who now teaches at the University of Georgia. Nowak added that people want certainty from the CDC rather than “what ifs,” and that they want to know “if you do believe in these vaccines, why do you show so much trepidation regarding these vaccines?”
Even former CDC director Frieden told STAT he believes the CDC “needs to be better at emphasizing with how sick and tired people are with restrictions,” though he largely defended the CDC’s guidelines.
“I have sympathy for the CDC,” said Frieden, who called making CDC guidance “an art and a science” that doing so “requires an encyclopedic knowledge of the data as well as a sensible way of interpreting the data and applying it to everyday life.”
“We want simplicity when there isn’t simplicity,” Frieden added.
Besser, the former acting CDC director, also acknowledged that certain CDC guidelines, including advice on what vaccinated people can safely do, were released later than he would have liked. He attributed the CDC’s slowness to a culture in which it “gets challenged in settings where the science is incomplete, or settings where the science may not exist at all.”
“It was one of the biggest challenges that I felt we had,” said Besser.
It’s clear vaccines are cutting transmission dramatically. But some “breakthrough” infections still do occur, and researchers are still trying to determine the level of risk posed to others by someone who is infected after vaccination. Some experts, Frieden included, still also worry fomites are a possible mode of transmission, and studies were still being published in peer-reviewed journals late last year claiming fomite transmission is possible, even if it’s not the dominant mode of transmission.
“I still don’t like to touch the lobby button of elevators,” Frieden said. “I think we were too concerned about it last year and I think we may minimize it too much this year.”
Defenders of the CDC insist it’s better for the agency to be cautious than it would be for it to get ahead of the science — and then being forced to walk back recommendations.
“The CDC wants to avoid making any sweeping new recommendations today that might have to be walked back tomorrow,” said Koh. “They’re being extremely cautious and I respect them for that.”
But those frustrated with the CDC’s approach insist that waiting for more certainly just isn’t an option.
“If their advice is too disconnected from reality, and if they are too slow, then they make themselves irrelevant,” Wen, the George Washington professor said. “I understand that they’re in a difficult position. However caution and indecision also comes at a price.”