"In early
February, 57 people arrived at a Nebraska military base, among the first
Americans evacuated from Wuhan, China, the epicenter of the new
coronavirus outbreak. U.S. health officials knew very little then about
the mysterious new virus, and the quarantined group offered an early
opportunity to size up the threat.
The
federal government sought help from a team at the University of
Nebraska Medical Center, including Dr. James Lawler, an experienced
infectious disease specialist. Lawler told Reuters he immediately asked
the world-renowned U.S. Centers for Disease Control and Prevention (CDC)
for permission to test the quarantined group, deeming it crucial to
know whether people without symptoms were infected and could spread the
deadly pathogen.
Agency
officials worried that detained people couldn’t give proper consent
because they might feel coerced into testing. “CDC does not approve this
study,” an official at the quarantine site wrote to Lawler in a Feb. 8
email obtained by Reuters. “Please discontinue all contact with the
travelers for research purposes.”
More
than two months passed before the CDC expanded its testing guidelines
to include all asymptomatic people, saying soon afterward that this
silent spread “may meaningfully contribute to the propagation of the
COVID-19 pandemic.” By November, the agency estimated that more than
half of cases were spread by people not currently experiencing symptoms.
Critics
have widely asserted that the CDC fumbled key decisions during the
coronavirus scourge because then-President Donald Trump and his
administration meddled in the agency’s operations and muzzled internal
experts. The matter is now the subject of a congressional inquiry. Yet
Reuters has found new evidence that the CDC’s response to the pandemic
also was marred by actions - or inaction - by the agency’s career
scientists and frontline staff.
At
a crucial moment in the pandemic when Americans were quarantined after
possible exposure to the virus abroad, the agency declined or resisted
potentially valuable opportunities to study whether the disease could be
spread by those without symptoms, according to previously undisclosed
internal emails, other documents and interviews with key players.
Soon
after balking at testing the returnees from Wuhan, the agency delayed
testing asymptomatic passengers among 318 evacuees from the Diamond
Princess, a contaminated cruise ship in Japan. In addition, the agency
failed at that time to make effective use of outside experts and
appeared at times unprepared for the crisis on the ground, lacking
adequate personal protective gear and ignoring established protocols,
Reuters found.
“Yes,
they were interfered with politically,” said Lawrence Gostin, director
of the O’Neill Institute for National and Global Health Law at
Georgetown University, referring to alleged meddling by the Trump
administration. “But that’s not the only reason CDC didn’t perform
optimally during COVID-19. There are a lot of things that went wrong.”
Four
top public health experts or ethicists told Reuters that the question
of whether to test or engage in research on detained people has always
been a sensitive topic. But all said the CDC should have proceeded given
the fast-moving public health emergency.
Moreover,
the CDC finalized rules in 2017 providing that medical testing was
expressly allowed in quarantine, as long as participants were given the
opportunity to give “informed consent” or opt out. Informed consent
means giving people adequate information to understand the risks and
benefits of a test or procedure.
Gostin
said the CDC’s argument against testing was “unreasonable” under the
circumstances. “You are asking for consent and not imposing any harm,”
he said. “There is a good reason to do it.”
It’s
difficult to know whether more aggressive early testing among
asymptomatic people would have significantly altered the trajectory of
the pandemic in the United States, which has infected 24 million people
and killed more than 400,000.
The
CDC was not the only agency that struggled with this issue. Notably, an
official with the World Health Organization called asymptomatic spread
“very rare” in June, only to say a day later “we don’t actually have
that answer yet.” In recent months, the WHO has said infected people
without symptoms can be contagious, but “it is still not clear how
frequently this occurs.”
Still,
some countries such as South Korea and Singapore used widespread
testing early on to identify infected people with or without symptoms
and, unlike the United States, broadly required or distributed masks.
CDC
scientists infamously botched the creation of a test for the
coronavirus and took weeks trying to fix it, making widespread testing -
well beyond those with symptoms - impossible during the pandemic’s
first months.
In response to detailed inquiries from Reuters, a CDC spokesman said the agency declined to comment.
In
the final weeks of the Trump administration, White House officials did
not respond to requests for comment on reports of political
interference.
The
problems within the CDC, which has suffered from a decade of declining
funding, point to the steep challenge faced by newly inaugurated
President Joe Biden and his CDC director, Rochelle Walensky, to
rehabilitate the agency in the eyes of scientists, other public health
officials and the public.
Walensky “acknowledges that work has to be done to restore public confidence” in the CDC, according to a Biden spokesperson.
Dr.
Sonja Rasmussen, who worked at the CDC for 20 years and at one point
was responsible for pandemic influenza preparedness, said the agency’s
staff are “among the most dedicated professionals in the world and they
were doing the best they could under the toughest circumstances.”
“This
has been an incredibly challenging pandemic and it would have been hard
for anyone to guess what would have happened,” she said.
But
she and other public health specialists also told Reuters that
Americans deserve a thorough examination of the agency’s shortcomings in
the crisis.
“We
have to figure out what needs to be fixed before this happens again,”
said Rasmussen, now a professor at the University of Florida.
REQUEST DENIED
On
Feb. 7, a group of Americans arrived from Wuhan and the surrounding
province at Camp Ashland, a National Guard base near Omaha and the
University of Nebraska Medical Center, a major outpost in the nation’s
defenses against bioterrorism and infectious diseases.
Infectious
disease specialist Lawler, who worked in the George W. Bush and Obama
administrations on pandemic response, suspected that some of the
evacuees might be infected with the coronavirus and shedding it despite
having no symptoms. His suspicions were based partly on scientific
reports from Asia and Europe.
Starting
on Feb. 8, Lawler pressed the CDC to greenlight voluntary and limited
coronavirus testing among this group, according to emails obtained by
Reuters through the Freedom of Information Act.
Lawler
had already won support for such testing from the U.S. Health and Human
Services (HHS) officials in charge of the returnees at Ashland, the
Nebraska health department and his university’s medical faculty, emails
show. HHS oversees the CDC.
Later
that Saturday, Eric Kasowski, the CDC’s representative at Camp Ashland,
emailed Lawler to tell him that his request to test the 57 people in
quarantine “was very quickly elevated to Dr. (Anne) Schuchat, Principal
Deputy Director, CDC,” who had worked at the agency for 32 years.
Schuchat referred questions from Reuters to the CDC press office, which declined to comment.
The CDC’s answer to Lawler was no.
According
to the Feb. 8 email: “It is CDC’s position that since the research is
being proposed for a group of individuals who are detained under a
federal quarantine order, the circumstances of voluntary participation
would be extremely difficult to assure and therefore, CDC does not
approve this study.”
Lawler
said he kept pressing Kasowski. But Kasowski told Lawler the next
morning that the testing proposal had been rejected again, this time by
officials up to and including CDC director Robert Redfield.
“This is absurd,” Lawler recalled telling Kasowski.
Kasowski declined to comment, referring questions to the CDC.
Instead
of having everyone tested during the two-week quarantine, only one
returnee who became ill and was hospitalized got tested; the results
were negative for coronavirus, Lawler said. The other 56 left quarantine
without knowing whether they carried the virus, and Lawler said he
knows of no CDC follow up with that group.
In
a Feb. 10 email to Kasowski, Lawler warned that the federal government,
by not testing symptomless individuals, “may be missing the submerged
iceberg in the U.S.”
MAJOR PROBLEMS
Within
days, Lawler got a new federal assignment: to help evacuate more than
300 Americans stranded on the Diamond Princess cruise ship docked in
Yokohama, Japan.
He
was joined there by Dr. Michael Callahan, a veteran infectious disease
specialist from Massachusetts General Hospital, who had just been
appointed a special advisor to HHS on COVID-19. Callahan, who says his
two years of physician scientist training at the CDC in the mid-1990s
inspired him to forgo academia for a field career battling disease
outbreaks, had just treated coronavirus patients in China weeks earlier.
Major problems emerged soon after Lawler and Callahan arrived in Yokohama on Feb. 14.
The
U.S. team, including HHS and other U.S. personnel, had to borrow walkie
talkies from Japanese authorities because they didn’t have mobile
phones that worked internationally, according to an “after-action”
report submitted by Lawler and Callahan in March to HHS and obtained by
Reuters.
Japan
had to lend the U.S. team basic protective gear because the Americans’
supplies didn’t arrive in time, the report said. Some team members were
not trained for handling a “highly contagious disease.”
According
to Callahan, he had to turn back two CDC staffers seeking to board the
Diamond Princess in Japan because they had no current experience in
emergency medicine and infection control.
Callahan
said the problem was not isolated to the CDC’s coronavirus response. In
his regular interactions in the field with CDC staff in recent years,
he said, he has seen “a progressive degradation of clinical expertise
and incident management,” particularly during Ebola outbreaks in Africa.
The CDC needs “people that can actually do public health when bad stuff happens,” Callahan said.
NOT ENOUGH PROOF
On
Feb. 17, Lawler flew with 151 cruise passengers to Lackland Air Force
Base near San Antonio, Texas. An isolation bubble was created using a
plastic curtain in the rear of the plane for five passengers who had
tested positive for COVID-19 in Japan.
During
the flight, Lawler moved two passengers who had become feverish to the
isolation area, planning to take them to Nebraska Medical Center. But
those precautions went awry when CDC personnel greeted the plane in
Texas.
“The
CDC officer in charge boarded the aircraft without consulting the
flight crew regarding safety or contamination issues,” according to the
after-action report.
The
officer’s personal protective equipment “was grossly insufficient due
to the high level of contamination that likely existed on the aircraft.
This likely put CDC personnel and other responders on the ground at
risk.”
What’s
more, the CDC official moved the two people who had developed symptoms
mid-flight back with the group of healthy passengers, and the CDC’s
handling of the flight violated disaster medicine protocols, according
to the report. The CDC official is not named in the report.
Similar
problems occurred when Callahan arrived with another group of 167
Diamond Princess passengers at Travis Air Force Base in Northern
California and a CDC officer boarded the plane, the report said.
Meantime,
officials at Nebraska’s public health laboratory, who had been working
with Lawler, asked the CDC for permission to test passengers from the
Diamond Princess while they were under quarantine, even if they didn’t
have symptoms, emails show.
A
CDC influenza expert, Dr. Tim Uyeki, wrote back on Feb. 17 to the
director of the Nebraska Public Health Laboratory that the agency only
wanted to test symptomatic individuals and those who had previously
tested positive in Japan, citing a lack of detail on the accuracy of the
Japanese tests.
Uyeki declined to comment and referred questions to the CDC press office.
Lawler
and Callahan said they flew in late February to CDC headquarters in
Atlanta to meet with Redfield and other senior officials, to raise
concerns about the flawed evacuation and potential for asymptomatic
spread based on their observations from the Diamond Princess.
Lawler said CDC officials replied that there wasn’t enough proof yet that people without symptoms spread the disease.
Redfield did not return requests for comment.
Meanwhile,
at both quarantine sites in Texas and California, CDC staff began to
test some cruise passengers without symptoms who previously had tested
positive in Japan, according to Dr. Bela Matyas, the local health
officer in California’s Solano County, as well as emails between the
Nebraska hospital personnel and the CDC.
The
CDC officials had doubts about the accuracy of testing done by Japanese
authorities, but the results confirmed that at least some of the
passengers were indeed positive - 16 at the California base alone,
Matyas said. Texas numbers were not available.
During
the second week of quarantine in late February, the CDC and local
health officials began offering tests to all of the cruise passengers.
In California, where most sought testing, 10 more people were found to
have COVID-19, Matyas said.
Despite
this evidence of infections without symptoms, the CDC made no immediate
changes in its public guidance on asymptomatic infection.
‘FAIRLY COMMON’
By March, signs of asymptomatic spread were mounting in the United States and abroad.
A
tipping point for the CDC came when staffers were deployed to the
outskirts of Seattle to handle an outbreak at the Issaquah Nursing and
Rehabilitation Center, a relatively confined setting. King County and
CDC officials tested 76 of the 82 residents, regardless of whether they
exhibited symptoms, beginning on March 13, according to the CDC.
They found 23 infected, 13 asymptomatic at the time. Ten of those went on to develop symptoms.
“That
was really ... our first hint that asymptomatic transmission was fairly
common, especially in those settings,” said Dr. James Lewis, an
official with the county health department’s COVID-19 response, in an
interview.
Two
weeks later, on March 27, the CDC published the case study as evidence
of asymptomatic infection. That same week, for the first time, the
agency recommended testing health workers and first responders, even
without symptoms.
In
a radio interview that aired on March 31, Redfield said, “We have
learned that in fact” symptomless individuals “do contribute to
transmission.”
Based
on that evidence, the CDC recommended that even asymptomatic people
wear cloth face coverings in public areas. Almost a month later, on
April 27, the agency expanded its testing guidelines to include “persons
without symptoms.”
That was 11 weeks after Lawler’s first request to test the Wuhan group in Nebraska."