The CDC: Of Revolving Doors and Dark Clouds and Chopping Blocks, Oh My

[UPDATE BELOW] The director of the Centers for Disease Control and Prevention, longtime government scientist Dr. Susan Monarez, was confirmed for her post by the Senate on July 29. Today, she's out. The story is still developing (The Hill), so it's unclear whether the decision was made by her immediate boss (HHS Secretary RFKJr) or by his boss DJTJr. She was the president's pick to begin with, so it's safe to say that he had to approve her dismissal and it seems likely the idea started with him, as well.

Nothing has been said so far by either HHS or the White House that would shed light on the reason for her firing. Stories have been flying around  about disquiet among CDC's rank and file employees following (1) the August 11 shooting at CDC headquarters in Atlanta that resulted in the death of a Dekalb County police officer, (2) mass layoffs at the CDC since January, (3) increased harassment of CDC employees by (among others) anti-vaxxers, and (4) chaos surrounding RFKJr's relentless dismantling of CDC's vaccine  infrastructure, including the dismissal of all members of the agency's vaccine advisory panel and defunding mRNA vaccine research.  (CBS News; NPR)

It hardly needs to be said that Dr. Monarez did not have a hand in any of these events and could hardly have turned the agency around against headwinds like these in less than a month on the job. Maybe Federal Housing Finance Agency Director Bill Pulte can unearth something wrong with her (pre-confirmation) home mortgage application, which seems to be the administration's preferred mode of political harassment these days (NBC, Aug. 27).

At this stage, it appears that the dark days at the CDC aren't going to lighten up anytime soon. And that's not good news for the rest of us.

Elections have consequences.

UPDATE (10:09pm CDT):

Late-breaking reports from the NY Times (and WaPo):

• Sources say the director was told by RFKJr to resign or be fired. The immediate issue was her refusal to support the unscientific policy against vaccines that had played out at HHS over the past 7 months.
• She was also told to fire key senior officials evidence-based policies toward vaccines differed from the Secretary's.
• Monarez refused to fire the senior officials and refused to resign.
• As of this evening:
• Monarez was fired as director of CDC. "[A]t 9:30 p.m. [EDT], a spokesman for President Trump, Kush Desai, said in an email message that Dr. Monarez had been terminated. . . .  Susan Monarez is not aligned with the President’s agenda of Making America Healthy Again,” Mr. Desai wrote. . . . "Since Susan Monarez refused to resign despite informing HHS leadership of her intent to do so, the White House has terminated Monarez from her position with the C.D.C.”
• The following senior officials have resigned:
• Dr. Debra Houry, the C.D.C.’s chief medical officer; 
• Dr. Demetre Daskalakis, who ran the center that issues vaccine recommendations; 
• Dr. Daniel Jernigan, who oversaw the center that oversees vaccine safety; and 
• Dr. Jennifer Layden, who led the office of public health data.
• Reactions to the firing and the resignations have been swift:
• Dr. Mandy Cohen, who ran the agency during the second half of the Biden administration, called the officials “exceptional leaders who have served over many decades and many administrations,” and warned that “the weakening of the C.D.C. leaves us less safe and more vulnerable as a country.”
• Dr. Anne Schuchat, the C.D.C.’s principal deputy director until her retirement in May 2021, called them “the best of the best.” “These individuals are physician-scientist public health superstars,” she said. “I think we should all be scared about the nation’s health security.”

In July, I wrote about the DOJ's decision to halt the prosecution of a Utah physician who perpetrated massive COVID-related fraud and praised the doctor's "heroism." My comment was that the DOJ had turned public-health law and policy on its head by lionizing a physician who should rightfully be regarded as a public health enemy.

Now, HHS and the White House have gone equally upside-down, this time by [1] firing a true public-health defender -- a career government scientist with an unblemished reputation for integrity -- and [2] effectively forcing out four senior CDC leaders who refused to buckle under the new administration's anti-vaccine agenda.

Elections have consequences.

Texas and Trump: Failing Grades on Abortion and Measles

A couple of recent articles show the impact of massive public-health failures on the part of both the state of Texas and the federal government.  And in both instances, public-health failures undoubtedly resulted in avoidable deaths.

1. Emergency obstetrical interventions delayed or withheld. Marin Wolf and her colleagues at the Dallas Morning News have published a series of articles ("Standard of Fear") beginning in the paper's Sunday (8/24) edition and continuing in the Monday (8/25) edition. (Warning: possible paywall.) An overview:

More than a year ago, The Dallas Morning News set out to explore how Texas’ overlapping abortion laws have altered the landscape of obstetric health care. Through more than 100 interviews with physicians and other health care professionals, researchers, advocates, legal experts, patients and family members, reporters documented deviations from the standard of care, as well as other unintended consequences.

A review of hundreds of pages of medical and death records, including the examination of more than a dozen patient cases, revealed how the laws have been sweeping in their collateral damage — with patients, families and medical providers caught in the middle.

Texas lawmakers have accomplished what they set out to do — criminalize and, thus, drastically reduce access to abortion. But in doing so, they have also derailed medical care for women trying to have children who developed heartbreaking or life-threatening problems in their pregnancies.

Many women — including those who never imagined they would want or need an abortion — have faced delays or denials of treatment. This includes patients with preexisting medical conditions that make pregnancy dangerous, ectopic pregnancies, miscarriages, the onset of labor before a fetus is viable and fetal diagnoses that are lethal or life-limiting. Others have grown too afraid of becoming pregnant in Texas — so much so that there has been an increase in surgical sterilizations.

In a state that leads the nation in maternal mortality, how can legislators possibly justify interfering with women's autonomy and making it more difficult to obtain potentially life-saving emergency obstetrical care? 

2. CDC dropped the ball on the West Texas measles outbreak. KFF News published an article this morning ("As Measles Exploded, Officials in Texas Looked to CDC Scientists. Under Trump, No One Answered.") that documents the impact of Trump-era cuts in staffing and funding at the Centers for Disease Prevention and Control. Here are some excerpts:

As measles surged in Texas early this year, the Trump administration’s actions sowed fear and confusion among CDC scientists that kept them from performing the agency’s most critical function — emergency response — when it mattered most, an investigation from KFF Health News shows.

The outbreak soon became the worst the United States has endured in over three decades. . . . 

Delays have catastrophic consequences when measles spreads in undervaccinated communities, like many in West Texas. If a person with measles is in the same room with 10 unvaccinated people, nine will be infected, researchers estimate. If those nine go about their lives in public spaces, numbers multiply exponentially.

The outbreak that unfolded in West Texas illustrates the danger the country faces under the Trump administration as vaccination rates drop, misinformation flourishes, public health budgets are cut, and science agencies are subject to political manipulation. 

And here's the kicker:

While the Trump administration stifled CDC communications, health secretary Robert F. Kennedy Jr. fueled doubt in vaccines and exaggerated the ability of vitamins to ward off disease. Suffering followed: The Texas outbreak spread to New Mexico, Oklahoma, Kansas, Colorado, and Mexico’s Chihuahua state — at minimum. Together these linked outbreaks have sickened more than 4,500 people, killed at least 16, and levied exorbitant costs on hospitals, health departments, and those paying medical bills. 

The federal-state public-health partnership was based upon indispensable monitoring data and expertise that could be mobilized in an instant to support local public-health officials working in affected communities to limit the damage of infectious disease. Instead, a bunch of no-nothings in this administration are ushering in a new Dark Age of illness and premature death. 

Elections have consequences.

U.S. Measles Cases Reach 33-Year High

Twenty-five years after measles was eliminated in this country, there have been 1,288 cases this year (as of July 8), according to the CDC. The epicenter of this year's cases is one of the leading vaccine-skeptical states, Texas, where over 700 cases have been reported this year:

Source: CDC

65% of the cases involve individuals under 20 years of age. CDC reports 3 deaths, including 2 unvaccinated children. Overall, 92% of the patients were either unvaccinated or their vaccination status was unknown.

Vaccine skepticism has likely received a shot in the arm from the ambivalence of RFK, Jr. As reported in The NY Times:

“The most effective way to prevent the spread of measles is the M.M.R. vaccine,” he added, referring to the measles, mumps and rubella vaccine.

At the same time, Mr. Kennedy has stopped short of recommending universal vaccination in communities where the virus is not spreading.

And he has ordered a re-examination of whether the vaccine causes autism, a claim long ago debunked by research, to be conducted by a well-known vaccine skeptic.

And as of this morning:

In a statement to NPR, Health and Human Services Department spokesperson Andrew Nixon said, "CDC continues to recommend MMR vaccines as the best way to protect against measles. The decision to vaccinate is a personal one." [emphasis added]

According to the World Health Organization, "herd immunity" for measles requires at least a 95% immunization rate, which is a standard only 11 states currently achieve. 

The lower the rate falls below 95%, the greater the risk to the community of an outbreak. Of the 40 remaining jurisdictions, 12 states have a vaccination rate below 90%. 

One of the contributing factors to the low rate of vaccination is permissive state laws that allow parents to opt their kids out of compulsory-vaccination for public-school enrollment. All states require some vaccinations, including the MMR (measles, mumps, and rubella) vaccine. But only 5 states limit parental exemptions to medical reasons. All 46 remaining jurisdictions add non-medical reasons for exemptions, including: religious, personal belief, or both.

Source: National Conference of State Legislatures

As expected, there is an almost-perfect correlation between these two maps: the vaccination rates >94% tend to be in the states that limit their vaccination exemptions to individual medical indications. 

The justification for non-medical exemptions is primarily -- if not entirely -- political, not legal. Although the issue has divided lower courts, one COVID-era Supreme Court opinion provides support for states that exclude religious reasons for vaccine exemptions as long as the state requirement is applied equally to religious and secular settings. Indeed, cases going back to the military draft during the Vietnam War -- cases that struggled to define and apply the draft law's religious exemption -- observed that Congress was not required to include a religious exemption at all (but when it does, it must do so without favoring one set of religious beliefs over others). 

I Really Didn't Plan to Post Anything Until My Next Sabbatical, But It's Time to Get Real (Part II)

The new administration is systematically undoing years and decades of support for the sorts of health- and medicine-related web posts and publications, as I described  in yesterday's blog post. A few concrete examples to illustrate the author's claims:

-- ABC News: Multiple Health Agency Websites On HIV, Contraception Taken Down To Comply With Executive Orders (KFF News, 2/3/2025):

Government agency webpages about HIV, LGBTQ+ people and multiple other public health topics were down as of Friday evening due to President Donald Trump's executive orders aimed at gender ideology and diversity, equity and inclusion. Some of the terms being flagged for removal include pregnant people, chestfeeding, diversity, DEI and references to vaccines, health and gender equity, according to officials at the Centers for Disease Control and Prevention who spoke to ABC News on the condition of anonymity. Entire databases have also been temporarily removed. (Wang, Portnoy, Haslett, Brownstein and Benadjaoud, 1/31)

-- One day after the inauguration, OMB instructed staff at agencies inside the Department of Health and Human Services to stop all external communications. The affected agencies included the Food and Drug Administration, the Centers for Disease Control and Prevention and the National Institutes of Health. As reported by the Washington Post, "The pause on communications includes scientific reports issued by the CDC, known as the Morbidity and Mortality Weekly Report (MMWR); advisories sent out to clinicians on CDC’s health alert network about public health incidents; data updates to the CDC website; and public health data releases from the National Center for Health Statistics, which tracks myriad health trends, including drug overdose deaths."

Bird Flu: It May Be Worse Than We Suspect

The Kaiser Family Foundation (KFF) just published a report on the bird flu with a pretty scary title: "How America Lost Control of the Bird Flu, Setting the Stage for Another Pandemic." What?!?

A few salient quotes:

• "Nearly a year into the first outbreak of the bird flu among cattle, the virus shows no sign of slowing. The U.S. government failed to eliminate the virus on dairy farms when it was confined to a handful of states, by quickly identifying infected cows and taking measures to keep their infections from spreading. Now at least 875 herds across 16 states have tested positive."
• "Experts say they have lost faith in the government’s ability to contain the outbreak. 'We are in a terrible situation and going into a worse situation,' said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada. 'I don’t know if the bird flu will become a pandemic, but if it does, we are screwed.'"
• "To understand how the bird flu got out of hand, KFF Health News interviewed nearly 70 government officials, farmers and farmworkers, and researchers with expertise in virology, pandemics, veterinary medicine, and more. . . . Together with emails obtained from local health departments through public records requests, this investigation revealed key problems, including deference to the farm industry, eroded public health budgets, neglect for the safety of agriculture workers, and the sluggish pace of federal interventions."
• "Far more bird flu damage is inevitable, but the extent of it will be left to the Trump administration and Mother Nature." No comment.
• "[T]the outbreak poses the threat of a pandemic. More than 60 people in the U.S. have been infected, mainly by cows or poultry, but cases could skyrocket if the virus evolves to spread efficiently from person to person. And the recent news of a person critically ill in Louisiana with the bird flu shows that the virus can be dangerous. . . . Just a few mutations could allow the bird flu to spread between people. Because viruses mutate within human and animal bodies, each infection is like a pull of a slot machine lever.
• “Even if there’s only a 5% chance of a bird flu pandemic happening, we’re talking about a pandemic that probably looks like 2020 or worse,” said Tom Peacock, a bird flu researcher at the Pirbright Institute in the United Kingdom, referring to covid. “The U.S. knows the risk but hasn’t done anything to slow this down,” he added.

CDC Reports on Intimate-Partner Violence

The full title of the CDC's report gives an accurate picture of the report's focus on intimate-partner violence "(IPV"): Intimate Partner Violence and Pregnancy and Infant Health Outcomes — Pregnancy Risk Assessment Monitoring System, Nine U.S. Jurisdictions, 2016–2022 (Dec. 5, 2025). 

The implications of IPV for public health, maternal health, and infant health are far-reaching, complex, and difficult to solve. Here's a snapshot of this important report:

Summary

What is already known about this topic?

Intimate partner violence (IPV) during pregnancy is a preventable cause of injury and death with negative short- and long-term impacts for pregnant women, infants, and families.

What is added by this report?

During 2016–2022, among women with a live birth in nine jurisdictions, 5.4% experienced IPV during pregnancy. Emotional IPV (5.2%) was more common than physical (1.5%) and sexual (1.0%) IPV. All IPV types were associated with delayed or no prenatal care, depression and substance use during pregnancy, and low infant birth weight.

What are the implications for public health practice?

Addressing multiple IPV types through comprehensive prevention efforts is critical to supporting maternal and infant health.

Abstract

Intimate partner violence (IPV) can include emotional, physical, or sexual violence. IPV during pregnancy is a preventable cause of injury and death with negative short- and long-term impacts for pregnant women, infants, and families. Using data from the 2016–2022 Pregnancy Risk Assessment Monitoring System in nine U.S. jurisdictions, CDC examined associations between IPV during pregnancy among women with a recent live birth and the following outcomes: prenatal care initiation, health conditions during pregnancy (gestational diabetes, pregnancy-related hypertension, and depression), substance use during pregnancy, and infant birth outcomes. Overall, 5.4% of women reported IPV during pregnancy. Emotional IPV was most prevalent (5.2%), followed by physical (1.5%) and sexual (1.0%) IPV. All types were associated with delayed or no prenatal care; depression during pregnancy; cigarette smoking, alcohol use, marijuana or illicit substance use during pregnancy; and having an infant with low birth weight. Physical, sexual, and any IPV were associated with having a preterm birth. Physical IPV was associated with pregnancy-related hypertension. Evidence-based prevention and intervention strategies that address multiple types of IPV are important for supporting healthy parents and families because they might reduce pregnancy complications, depression and substance use during pregnancy, and adverse infant outcomes.

As a side note, this report is an example of the sort of data collection and dissemination that may be at risk in the Trump administration. It appears that the president-elect's advisors, as well as members of Congress, are looking to cut the CDC's budget and scale back some of its public-health activities. I hope cooler heads will prevail, but "Hope is that thing with feathers." 

Health Affairs: "The Impact Of The Election On Health Policy And The Courts"

The nonpartisan and highly respected journal, Health Affairs, today posted an analysis of some of the more conspicuous (and worrying) changes to the health care scene we might expect to see once Donald Trump's administration is in place. It is, as usual, well worth reading in whole.

The areas that are discussed include:

• the Affordable Care Act (ACA) (primary concern: allowing premium tax credit enhancements to expire entirely after 2025, which could result in 4 million people losing their health insurance coverage; also -- whether by statute, agency regulation, or executive order -- any number of the ACA's protections are at risk)
• Medicaid (during the campaign Trump vowed to leave Social Security and Medicare alone; "experts noted that Medicaid was conspicuously absent from the conversation")
• reproductive health care (abortion, LGBTQ nondiscrimination, reviving the Comstock Act, changing the Administration's position in state and federal lawsuits)
• nondiscrimination and health equity ("Health care is a civil rights issue. . . . Anti-discrimination protections in health are also likely to suffer major blows going forward."
• Medicare Drug Negotiation Program (hard to believe that a program that will save the government and citizens billions will be watered down, but Big Pharma has hated this law from the beginning and it has some attentive allies in the new administration)
• public health (RFK, Jr. -- need I say more? He was named as Trump's nominee for Secretary of HHS; the mind reels)
• the courts (Yup. From the Supreme Court on down, expect change)

The end. (Take that any way you want.)

CDC Updates Guidance on COVID+ Infections

I noted in an earlier post that the Center for Disease Control & Prevention (CDC) was considering a significant change to their recommendations for patients who test positive for Covid-19 ("Chicken Soup for COVID?", 2/18/24). Things got busy at work, and I neglected to post a link to the final version of the recommendations, which CDC pushed out on March 1. You can find the press release here and the text of the recommendations here.

The new guidelines fairly drastically reduce the agency's previous quarantine recommendation:

When people get sick with a respiratory virus, the updated guidance recommends that they stay home and away from others. For people with COVID-19 and influenza, treatment is available and can lessen symptoms and lower the risk of severe illness. The recommendations suggest returning to normal activities when, for at least 24 hours, symptoms are improving overall, and if a fever was present, it has been gone without use of a fever-reducing medication.

Once people resume normal activities, they are encouraged to take additional prevention strategies for the next 5 days to curb disease spread, such as taking more steps for cleaner air, enhancing hygiene practices, wearing a well-fitting mask, keeping a distance from others, and/or getting tested for respiratory viruses. . . .

For all intents and purposes, the CDC recommends the same steps for dealing with COVID as for influenza. The absence of fever for 24 hours, not a negative COVID test, is the key to ending quarantine and returning to a mostly normal life. "Normal" in this case includes limiting close contact with others, wearing well-fitted masks, improving indoor air quality, and practicing good hygiene.

Chicken Soup for COVID-19?

Earlier this week, NBC reported that the CDC is considering a substantial change to its isolation guidelines for individuals who are COVID+. Under the proposal, individuals with COVID would be allowed to re-enter society 24 hours after they are fever-free without medications. In essence, according to the report, CDC's recommendation would be to treat COVID like the flu.

Soon after the NBC story broke, an anonymous official at DHHS emphasized there is no change yet, meaning their 5-day isolation/10-day masking guideline is still in effect, at least until it isn't, pointing out that "discussions are at an early stage and no definitive decisions have been made."

Outside the Washington Beltway, support for the change seems to be building:

Dr. William Schaffner, an infectious diseases expert at Vanderbilt University Medical Center in Nashville, Tennessee, said he and his colleagues have privately encouraged the CDC to drop the five-day isolation period, in part because there’s little evidence it’s stopping the spread of Covid. 

The “rigorous recommendations that are currently in place do not reflect common practice,” Schaffner said. “It’s difficult to demonstrate that strict isolation has had a notable impact on transmission.” 

California and Oregon have already broken with the CDC, suggesting that people don't need to stay home if they've been fever-free for 24 hours without medication.

“With each day, the risk of communicability diminishes,” Schaffner said. “Public health recommendations have to be practical.” That is, people may stay home for a few days if they have a fever and feel achy and fatigued. After that, it’s back to business as usual.

Dr. David Margolius, the public health director for the city of Cleveland, said he was also in favor of easing isolation restrictions.

“For a couple years, people really associated public health with the elimination of Covid,” Margolius said. But “public health is about increasing life expectancy for our residents. It’s about improving quality of life. And that is more than just controlling one virus.”

Covid is still contagious, said Dr. Abraar Karan, an infectious disease physician at Stanford Medicine. “What the CDC and health departments are trying to say is that we need to have policies that people are going to actually follow,” Karan said.

As of this month, emergency room visits, hospitalizations and deaths from Covid are down, according to the latest CDC data.