Following a recent webinar hosted by the Association of Health Care Journalists, three former top-level CDC officials who resigned in the wake of director Susan Monarez’s dismissal shared their perspectives on the internal turmoil at the agency and where physicians can turn for public health information as the agency makes moves away from evidence-based scientific recommendations.

Demetre Daskalakis, MD, MPH, former director of the CDC’s National Center for Immunization and Respiratory Diseases; Debra Houry, MD, MPH, CDC’s former chief medical officer and deputy director for Program and Science; and Daniel Jernigan, MD, MPH, agency’s former director of the National Center for Emerging and Zoonotic Infectious Diseases, described a federal agency whose scientific integrity and ability to function had been undermined by indiscriminate budget cuts, haphazard organizational changes, and rapid-fire policy changes without consideration for the scientific process or the various protocols that have historically governed decision-making at the agency. Cuts were made to programs despite those programs being central to US Department of Health and Human Services priorities, they said.

In addition, about 80% of CDC leadership positions are currently vacant, according to a recent report by the independent group CDC Data Project. Nearly 20 of 25 director positions at CDC are not filled, after those in the roles resigned or were “forced out,” according to the site.

In the midst of these changes, it has become challenging to understand what aspects of the CDC’s functions are reliable and which ones are not.

What This Means for Clinicians and the Public

While most existing infectious disease surveillance systems at the CDC appear to be functioning as they should currently, fewer analyses of surveillance have been forthcoming from the agency, according to former CDC officials.

“Bits and pieces of the CDC, such as the website, are getting a bit more suspect as we go forward,” Daskalakis said during the webinar. “It’s hard to necessarily predict where the uncertainty is going to be. One of the notable things about this secretary is that he is trying to create a wedge between doctors and their patients, and that should be a red flag for anyone.”

Beyond scientifically dubious statements on autism and vaccines and a reduction in the number of recommended childhood vaccines, however, it’s harder to identify where blind spots and weak spots are or will be.

Daskalakis said he’s directing people to rely more heavily on local and state health departments as reliable sources for public health information. There’s variability in that — Florida’s state public health department has notoriously made several recent decisions contrary to current evidence — but that’s where medical and public health organizations can further fill in the gaps. He highlighted groups such as the American Academy of Pediatrics, the Infectious Diseases Society of America, the American Medical Association, and the American College of Obstetricians and Gynecologists as entities putting out evidence-based public statements and helpful recommendations. Organizations like CIDRAP are also working to fill in those gaps, such as that center’s Vaccine Integrity Project.

Jernigan echoed Daskalakis’s concern about vaccine safety and reports on vaccine recommendations as being problematic, but he also worries about the dysfunction spreading to completely unrelated issues, such as infant botulism outbreaks or reports on unpasteurized milk. “If we don’t hear about those kinds of things, that’s where I know that we’ll be in a more difficult place,” he said.

Overview of Current Surveillance Reliability

While there are CDC functions that are no longer reliable, many others continue to function relatively normally for now, including some in domestic disease surveillance, according to Houry. However, global surveillance and analysis of domestic surveillance are both suffering, and it’s not clear how long currently functioning systems will continue.

“We have less visibility globally,” Houry told Medscape Medical News, with the CDC getting about 60%-70% fewer global viral samples for diseases such as flu and COVID, “so the US has less visibility on strains and what threats could be coming,” she said. The US withdrawal from the World Health Organization has also damaged the CDC’s ability to carry out some of its previous functions, and if further budget cuts affect the agency’s global work, that could cripple it further.

“You need to be able to know what’s going on with overseas surveillance and monitoring to see what things are emerging,” Houry said. “You need to be able to send people over quickly to get rid of those things or mitigate them before they come to the US, and the best way to do that is to have CDC staff in place there. Anything that risks us being able to know what’s going on or have people there to respond quickly will put us at greater risk for these emerging problems that will occur globally.”

Again, however, a lot of uncertainty exists regarding the extent to which that might happen. Cracks are visible now, but it’s unclear how wide they will get.

“The bottom line is that disease surveillance is happening, but CDC is not putting out materials like they had in the past discussing the findings,” Houry told Medscape Medical News. “If some of the funding cuts happen in January when the continuing resolution expires, some disease surveillance will falter, like HIV.”

Respiratory syncytial virus (RSV) and COVID were not tracked during the government shutdown, Houry said, but they have since resumed with weekly updates. Daskalakis said that FluView remains up-to-date and reliable, and case reporting is still reliable as far as he is aware. State and local health departments are still reporting surveillance, testing, and relevant contact tracing to the CDC.

It’s less clear how H5N1 is being addressed. The CDC continues to support jurisdictions when there is a case reported, as they have in the past, but there is no current Epi-Aid request for H5N1, so Daskalakis isn’t sure whether there is an Epidemic Intelligence Service officer assigned to H5N1.

In the meantime, clinicians have a range of other options for keeping their pulse on disease surveillance. Daskalakis again highlighted the value of state and local health departments in most jurisdictions.

“State and local health departments should help the people they represent sort signal from noise as CDC becomes less reliable,” he told Medscape Medical News.

Yale School of Public Health’s PopHIVE project is currently one of the best nonfederal sites collating surveillance data from multiple sources, such as Google Trends API, Epic Cosmos, and various CDC sources, Houry said.

Among the CDC surveillance networks that PopHIVE tracks and which still appear to be reliable are RESP-NET, the National Syndromic Surveillance Program, the National Respiratory and Enteric Virus Surveillance System, the National Wastewater Surveillance System, the National Healthcare Safety Network, and the Active Bacterial Core surveillance network. PopHIVE’s Respiratory Diseases dashboard tracks RSV, flu, COVID, and pneumonia.

Epidemiologist Caitlin Rivers publishes a weekly surveillance report on Substack that’s free during the winter respiratory season, and Daskalakis highlighted epidemiologist Katelyn Jetelina’s Your Local Epidemiologist, which often includes surveillance updates, as doing a “fabulous job” of extracting data and translating it into something more understandable and accessible for a broader audience.

Houry also called attention to the Common Health Coalition, which is a partnership of public health and health care systems, and the regional collaboratives formed this year: the West Coast Health Alliance of California, Oregon, Washington, and Hawaii; the Northeast Public Health Collaborative of nearly a dozen northeastern states; and the 15 states currently comprising the Governors Public Health Alliance.

“These are not to replace a federal public health agency,” Houry added. “I don’t know if CDC will survive, to be quite frank, with what they’re doing, but I do think we need a federal public health agency, and I view the regional collaboratives as groups that are innovating on top” [of a federal entity].

Jernigan also warned about the risks of too much splintering of public health information.

“We want to make sure that we don’t distribute the work of public health and the CDC to so many places that it cannot at some point be available to be reconstituted, and I do think there will be a time when we’ll be able to do that,” Jernigan said.

Looking to the Future

Daskalakis said he worries particularly about marginalized populations and the inevitable loss of data about them that could be used to prevent further harm from infectious disease. A key example, he said, was a decision by the Department of Government Efficiency (DOGE) to close the primate lab used for HIV research, which Science reported a few days after Daskalakis announced it during the webinar.

“That is the lab that does the preclinical work for HIV prevention,” work that drug manufacturers, academics, and the National Institutes of Health cannot do, he said. “That means that the lab responsible for figuring out which agents may be important in preventing HIV, by having an animal model that allows you to see if it prevents infections in animals, will be no more,” Daskalakis explained. “And why? Because someone at DOGE decided that. What does that mean for Americans? Fewer options for HIV prevention.”

The new HIV prevention agents coming out now, such as the long-acting preexposure prophylaxis agents cabotegravir and lenacapavir, began with preclinical research in the Division of HIV Prevention’s primate lab. “That means people will get HIV,” said Daskalakis.

Like Houry, Daskalakis also expressed concern about how the CDC’s decline will affect public health across the world given its role as the only US agency whose primary function is both domestic and global. “A vacuum created by CDC is going to mean sort of a vacuum globally,” he said, and that has implications for Americans, too, in terms of disease information surveillance.

But he, as well as Jernigan and Houry, said there are glimmers of hope, particularly in the scientists and public health civil servants still working behind the scenes at the CDC to preserve and promote as much science as they can.

“The hope is in the folks at the CDC and the folks who are on the outside, thinking about how to mitigate [the damage] and keep looking after the health of people in America and the globe,” Daskalakis said.

Administration Changes Unexpected

Recent changes at the CDC were surprising to staff in the departure from typical administration priority shifts.

“I’ve been at the CDC for 31 years, through multiple different administration changes, Republicans and Democrats, and each has their own characteristics and ideology, but the means by which they execute those ideologies — that was the thing that was very different in this administration,” Jernigan said. “You had the secretary come in with a set of priorities that didn’t match either the staffing that he had remaining [after cuts] or the dollars that had been put forward. This disconnect between who was making different changes to the government — I’ve never seen that in prior administrations.”

The result of all this, Houry said, is an agency that is wholly unprepared for the inevitable public health threats that the nation and the world will continue to face.

“I think there’s so much going on in the world today that people aren’t going to realize until there is that next pandemic or next health threat — and there will be — that more people die because CDC isn’t there to protect them,” Houry said.

“The real problem, I think, was the choice of not going with science as your primary driver for policymaking, and if there were any way that we could have tried to mitigate that some….I think I did not fully anticipate how much the terminology of radical transparency and gold standard science would be just turned on its head,” Jernigan said. “The secretary has been trying to have conclusions first and figure things out later, what somebody described as going from evidence-based decision-making to decision-based evidence-making. I was not prepared for it to be quite as in-your-face with that disregard for the science and the scientists.”

All three agreed that the clearest area of failure is with the new leadership’s “weaponization of the infrastructure around vaccines,” as Daskalakis put it. The changes to the autism and vaccines webpage Daskalakis told Medscape Medical News after the webinar those changes did not follow the usual processes for scientific review and instead “cherry-picked studies to align with the secretary’s agenda instead of using gold standard science and doing a robust review with most weight given to high-quality studies.”

Daskalakis, Houry, and Jernigan reported having no conflicts of interest.

Tara Haelle is a science and health journalist based in Dallas.