On February 13, the United States Centers for Disease Control and Prevention sent an email calling the author “URGENT” for help.
The agency struggled with one of its most important tasks: to keep track of Americans suspected of having the new corona virus. There was a “persistent problem” with the organization – and sometimes loss – of forms sent by local authorities about infected people. The email lists job advertisements for people who can track or access these documents.
“Help is urgently needed,” wrote the CDC.
This email is one of hundreds of pages of correspondence between federal and state health authorities that ProPublica received in Nevada on request.
During the period that the correspondence was being written, from January to early March, health officials tried to stay one step ahead of the Coronavirus outbreak in China. In mid-February, when the CDC email alert was posted, the virus was located in the United States, where there were already 15 confirmed cases. In another two weeks, the first community transmission case would be reported in California, followed by cases in Washington.
The documents – mostly emails – provide a behind-the-scenes look at the chaotic early stages of the U.S. response to the coronavirus, and reveal an outdated public health system that is trying to adapt on the fly. What is particularly noticeable is confusion as the CDC underestimated and stumbled upon the virus threat when it told local health authorities what to do.
In the same week that the CDC sent the job vacancy email, the Nevada agency sent warnings about 80 potential coronavirus patients for surveillance, according to documents. Four were not Nevada residents.
In any case, a state epidemiologist corrected the agency and informed the CDC that the person was from New York and not from Nevada. (The CDC then forwarded each report to New York, as the documents show.)
The confusion sometimes went both ways. On March 4, a program manager at the Nevada Health Department contacted the CDC to inquire about Congress funding for COVID-19, the disease caused by the novel coronavirus.
“For this purpose, there appears to be a communication outage,” the program manager wrote, wondering if funds would be distributed based on the number of cases in each state or by population.
“Unfortunately, there is no clear answer to your questions,” replied a CDC representative, apologizing for the lack of information. “We also hear all the rumor mill.”
“Thank you,” replied the Nevada program manager. “It’s good to be confused with each other.”
Throughout much of February, the CDC had a firm grip on who should be tested for coronavirus, a strategy criticized by epidemiologists to limit their ability to track the spread of the disease.
In a presentation to state health officials on February 19, the CDC outlined the definition of a person to be tested: they must have had close contact with someone who was confirmed to have COVID-19, or had traveled from China and then had respiratory problems and fever at the same time.
However, a month earlier, the CDC’s guidance issued to the states on January 17 included a footnote stating that “some patients may not have a fever,” for example, those who took antipyretic drugs, one of those from ProPublica received documents. This limitation was not included on the transparencies that were presented to the states in mid-February.
In a statement to ProPublica, the CDC said clinicians could always use their judgment to decide who received a test. “CDC never refused a test request from a state or local health agency,” the agency said.
In mid to late February, the CDC attempted to shift responsibility for coronavirus testing from itself to government health departments – a crucial step as the CDC does not have the capacity to be the national test laboratory. Slides from the February 19 presentation presented the transition from Phase 1, in which the CDC determined who was a potential COVID-19 patient, and performed all tests, to Phase 2, in which the local health departments doing that would work and report data back to the CDC.
Due to delays in test kits, phase 2 had to be “redesigned”, the presentation says, so that the CDC could continue to test samples and return results. The CDC informed ProPublica that all states have now moved on to the original Phase 2 plan, in which they can conduct their own tests.
The CDC presentation also instructed states to use a web platform called DCIPHER, which the agency already used for food-borne outbreaks to report potential COVID-19 patients and confirmed cases.
But it wasn’t until the week of February 24, the same week that the United States would discover its first case of COVID-19 from the community, that the CDC was planning to train states to use the Documentation platform.
On March 1, the CDC emailed the Nevada Health Department asking them to send a list of users and email addresses to connect to the DCIPHER system to ensure that we had your jurisdiction can take over.
“We sent a spreadsheet a few weeks ago that I thought would cover this,” replied a government epidemiologist.
Four days later, Nevada announced its first confirmed case of the coronavirus. It is unclear when the state has successfully entered the DCIPHER system. Nevada officials declined to comment.
“Maybe just kidding”
A key part of the CDC strategy in the early days of the outbreak was identifying infected travelers returning from China. The process of checking passengers arriving at Los Angeles International Airport was not a smooth one, according to the correspondence received from ProPublica.
On February 16, a CDC employee sent a message to colleagues about a faulty electronic travel screening questionnaire that, among other things, could not be saved correctly. In addition, the tool’s drop-down box is automatically populated with “United Kingdom” instead of “United States”, forcing users to enter “United States”.
The CDC staff member also said that the agency had difficulty interviewing non-English speakers in time and needed additional interpreters.
“Hello team,” another CDC representative replied, offering a solution: “The Google Translate app has a real-time language translation option.”
The screening protocol was also not always clear. On February 29, a CDC employee at LAX emailed her colleagues saying, “If this happens again, we will not check private flights. These would be flights that land in LAX but don’t arrive at the regular terminal … mainly for rich people. “
Just over two hours later, the officer sent another email. “And maybe just kidding,” she wrote. Headquarter information seemed to contradict what she said about private flights, she said.
The CDC informed ProPublica that it had increased the screening almost overnight, and therefore focused on screening the largest possible segment of high-risk passengers from places like Wuhan, China. The agency trained staff and dealt with limited human resources and translation services as much as possible.
“Protecting Americans is What We Do”
The CDC’s first response to COVID-19, particularly its failure to launch rapid and widespread testing, has generated widespread criticism.
However, the correspondence received by ProPublica shows that the CDC director, Dr. Robert Redfield, who radiated confidence in communicating with other agency staff.
On January 28, when the CDC confirmed five cases of the corona virus, all from travelers who traveled from outside the country, he emailed colleagues to acknowledge that this was “a very serious public health threat” However, assured them that the virus is not currently common in the United States. “
In fact, that may not have been the case. The CDC confirmed the first case of COVID-19 in Washington on January 20. Trevor Bedford, a computer epidemiologist at the Fred Hutchinson Cancer Research Center in Seattle, believes the virus may have been circulating in the state immediately after the state traveler arrived in mid-January, based on his analysis of genetic data from the first cases in Washington.
The CDC said in its statement that Redfield’s comments were based on the data available at the time. “At no time did he underestimate the potential of COVID-19 as a global pandemic,” the agency said. “He consistently stated that more cases, including person-to-person spread, are likely.”
On March 3, Redfield wrote to his staff again, emphasizing the agency’s willingness, despite growing evidence that this was not the case. “We expected and prepared for the possible spread of COVID-19 in US communities,” he said in an email.
The CDC said in its statement that Redfield informed employees that the agency would continue to respond sustainably to COVID-19. Redfield’s email did not characterize the condition of the outbreak, the CDC said.
At that point it was clear that the coronavirus was gaining ground within the country, even if the inability to test it masked the real numbers. Doctors and public health experts asked for further tests and warned that thousands of cases would soon occur.
Still, Redfield’s March 3 email was reassuring.
“We are dealing with global outbreaks and protecting Americans,” Redfield wrote in the message. “More and more people are turning to us for advice, and we are consistently responding with evidence-based information and professionalism.”