Testimony from Mandy K. Cohen, M.D., M.P.H. on Unmasking Challenges CDC Faces in Rebuilding Public Trust Amid Respiratory Illness Season before House Committee on Energy and Commerce

Chairman Griffith, Ranking Member Castor, and distinguished members of the Subcommittee, it is an honor to appear before you today.  For nearly 80 years, CDC has been the nation’s leading public health service agency, putting science and data into action to help people and communities stay healthy.  CDC prevents, detects, and responds to health threats at home and abroad to protect the country’s health, safety, and security.  We are seeing more infectious disease threats than ever before, including respiratory viruses like COVID-19 and avian influenza, and other highly concerning viruses like polio, malaria, mpox, Ebola, and Marburg. We need a CDC that is trusted and has the tools to quickly and effectively respond to the next public health threat.

To fulfill our full mission, we are applying lessons learned from the pandemic across three domains so that we can successfully protect the health of Americans:

1. Rapidly detecting and responding to health threats;
2. Providing timely, commonsense, and evidence-based solutions to protect and improve health; and
3. Building towards a broader integrated, effective system that protects the public’s health.

CDC is focused on achieving these goals with lessons learned in our efforts to prepare and respond to seasonal increases in COVID-19, influenza (flu), and respiratory syncytial virus (RSV).

Rapidly Detecting and Responding to Health Threats

In the past four years, we faced one of the greatest public health challenges of our generation: the COVID-19 pandemic.  But as we have transitioned out of the COVID-19 emergency, we must remember that this is not the only respiratory disease threat facing our nation.  Last fall, we saw the resurgence of seasonal respiratory viruses, with rates of flu returning to a range seen prior to the pandemic and RSV-related hospitalizations 1.5 times higher than that seen in typical RSV seasons (typically fall-winter).  The simultaneous high circulation of these three respiratory viruses took a toll on the U.S. health care system and pushed many hospitals beyond their capacity.

Respiratory illness causing people to seek health care for fever and cough is currently increasing in most areas of the country.  Hospital bed occupancy and capacity, including within intensive care units, remain stable nationally.

• Flu activity continues to increase throughout much of the country, most notably in the South Central, Southeast, Mountain, and West Coast regions and is expected to continue to increase in the coming weeks.
• COVID-19 activity remains elevated and emergency department visits and hospitalizations increased slightly within the past week.
• RSV activity is elevated across the country, particularly in young children, which indicates the start of the 2023-2024 RSV season. However, CDC anticipates that RSV infections will return to pre-pandemic levels and be lower than the surges seen last respiratory virus season based on elevated population immunity and new RSV prevention tools available this season.

Rapid detection and response require faster and more transparent data for all users—from clinicians and epidemiologists to individuals trying to use the latest public health data to protect their health.  CDC is applying lessons learned from the COVID-19 pandemic to let Americans know about the risk for illness in their communities.  For example, on September 14, CDC released the first fall and winter respiratory disease season outlook, sharing expectations for the severity of COVID-19, RSV, and flu hospitalizations for the 2023-2024 season.  This outlook is updated periodically, based on expert analysis, historical data, and scenario modeling to provide decision-makers information to assist with public health preparedness planning, including potential surges in hospital demand.

CDC projects that this respiratory disease season we will likely witness a similar number of hospitalizations as we observed last season, which were higher than those historically observed pre-pandemic.  Unfortunately going forward, this means that with the addition of COVID-19 circulating in our communities, even a moderate flu and RSV season will result in more hospitalizations from respiratory illness during the fall and winter than we observed in years prior to the pandemic, increasing strain on already stretched health systems.

In addition to these forecasts, CDC is leveraging our surveillance networks and laboratory capacity to rapidly detect changes in both the circulating flu virus and SARS-COV-2, the virus that causes COVID-19, so that we can act upon these findings to protect the public’s health.  CDC conducts year-round surveillance of circulating flu viruses to monitor changes in the genome of these viruses.  Similarly, CDC uses viral genomic surveillance to quickly identify SARS-COV-2 variants. This month, CDC announced a new pilot that will expand our Traveler-based Genomic Surveillance (TGS) program, which acts as an early warning system to detect new and rare variants of certain infectious diseases and fill gaps in global surveillance, especially where testing and reporting are limited.  The program consists of voluntary nasal sampling of arriving international travelers, and aircraft and airport wastewater sampling.  The pilot will include testing and genomic sequencing for flu, RSV, SARS-CoV-2, and other select respiratory pathogens.  The information CDC collects from studying genetic changes in flu and SARS-COV-2 viruses helps to determine whether vaccines and antiviral drugs will work against currently circulating viruses, to inform regular updates to the seasonal flu shot in collaboration with the Food and Drug Administration (FDA) and prepare for seasonal respiratory viruses and those viruses capable of causing a pandemic.

CDC is also increasingly leveraging tools, such as wastewater surveillance, to work with state and local public health jurisdictions to rapidly detect disease spreading in their communities.  State, tribal, local, and territorial health departments participating in the National Wastewater Surveillance System (NWSS) submit testing data to CDC, which we make publicly available.  Currently, NWSS includes 1500 sampling sites, capturing data representing 140 million Americans in 50 states.  Wastewater data can alert communities to diseases before hospitals and clinics begin to see a rise in cases and can provide insights on disease trends in places where clinical data are lacking.  Health departments, community leaders, and individuals can use this information to make decisions about how best to protect their community.  This week, CDC launched an updated data dashboard to enhance visualizations and help clearly communicate information on COVID-19 in wastewater that can be translated into action.

Providing Timely, Commonsense, and Evidence-based Solutions to Protect and Improve Public Health

As we navigate another fall and winter season, we must ensure we are doing everything possible to protect Americans against the most severe effects of these respiratory viruses.  To that end, CDC is applying lessons learned from the pandemic to further protect public health.  For example, we are actively working to ensure Americans receive clear and timely information from CDC about our best guidance for protecting their health.

Vaccination against COVID-19, flu, and RSV remains the safest protection for avoiding hospitalizations, long-term health impacts, and death. CDC continues to encourage Americans to stay up to date on all of their recommended vaccinations.  This is a top priority for CDC, and there is good news: for the first time ever, immunizations are available for all three major fall and winter respiratory diseases.

This year, we have supported the rollout of breakthrough developments in the fight to prevent RSV, which can result in severe hospitalization and death for both young children and the elderly.  In the United States, RSV infections cause an estimated 58,000–80,000 hospitalizations among children aged <5 years and 60,000–160,000 hospitalizations among adults aged ≥65 years each year.  CDC recommends that adults aged 60 years and older talk to their health care provider to see if receiving a single dose of one of the two approved vaccines is right for them.

To protect infants, we have two new immunization strategies.  During RSV season, CDC recommends a RSV vaccine between 32-36 weeks of pregnancy to protect infants after birth. Additionally, we now have a new immunization for infants that has been shown to reduce the risk of both RSV-related hospitalizations and health care visits in infants by about 80 percent.  This new immunization, a preventive antibody called nirsevimab, is currently in limited supply for this respiratory season.  Therefore, CDC has issued a Health Alert Network (HAN) advisory to clinicians, recommending prioritizing available nirsevimab 100mg doses for infants at the highest risk for severe RSV disease: young infants (age <6 months) and infants with underlying conditions that place them at highest risk for severe RSV disease.

In addition to new recommendations for RSV, in September, CDC recommended the updated COVID-19 vaccine for everyone 6 months and older.  The COVID-19 vaccines approved and authorized for use in the United States continue to reduce the risk of severe disease, hospitalization, and death, including against the most common variants currently circulating.  Getting a COVID-19 vaccine is a safer, more reliable way to build protection than getting sick with COVID-19, which can potentially lead to severe illness or post-COVID conditions (also known as Long COVID).  By the end of 2022, COVID-19 vaccines helped prevent 18.5 million COVID-19 hospitalizations and 3.2 million COVID-19 deaths in the United States.¹

Similarly, CDC recommends that everyone 6 months and older receive an annual flu vaccine, with those 65 and older receiving a higher dose or adjuvanted flu vaccine.  Flu and COVID-19 vaccines reduce the risk of severe illness, hospitalization, and death. These vaccines are safe and effective and have been administered safely to hundreds of millions of Americans.

In addition to vaccination, there are tools available to help prevent severe illness.  Rapid antigen tests for COVID-19 are widely available over the counter and should be used for those experiencing symptoms to help in accessing timely treatments and to inform actions individuals can take to protect others. Testing for flu or COVID-19 can also be done through your health care provider. In addition, the ICATT program continues to provide no-cost COVID-19 testing for uninsured people that are symptomatic or exposed.

Effective treatments for COVID-19 and flu, called antivirals, are widely available and can reduce the risk of severe illness, hospitalization, and death from these infections.  Antiviral drugs can reduce the severity and duration of illness when treatment is started within 1-2 days after flu or COVID-19 symptoms begin.  They might also prevent some complications, like pneumonia.  For people at higher risk of serious flu or COVID-19 complications, treatment with antiviral drugs can mean the difference between milder or more serious illness possibly resulting in a hospital stay.

Building a Broader, Integrated, and Effective System That Protects the Public’s Health

As we look forward, it’s critical that the future of public health build upon and strengthen the infrastructure and systems developed during the pandemic response.  Over the last three years, the U.S. Government and our partners effectively implemented the largest adult vaccination program in U.S. history, with over 700 million doses of COVID-19 vaccines given to 270 million Americans.  Fighting COVID-19 remains a key public health priority for the Administration, and ensuring that all Americans have continued, easy access to COVID-19 vaccinations and treatments, regardless of insurance status, is critical to that goal.  With this transition, most people living in the United States currently still have access to no-cost COVID-19 vaccines through private health insurance or other health insurance plans, such as Medicare, and Medicaid.  However, there are an estimated 25-30 million adults without insurance in the United States, and there are additional adults whose insurance will not provide free coverage for COVID-19 vaccines.

On September 15, CDC launched the Bridge Access Program to provide no-cost COVID-19 vaccines to eligible adults through December 31, 2024.  Eligible adults can get COVID-19 vaccines from select pharmacy chains, local public health providers, or Health Resources and Services Administration (HRSA)-supported health centers participating in the Bridge Access Program.  Individuals can visit vaccines.gov to find providers participating in the Bridge Access Program.  Retail pharmacies procure vaccines directly from the manufacturers to implement the pharmacy component of this program.  To date, nearly 360,000 vaccines have been distributed to jurisdictional immunization partners nationwide through this program and more than 560,000 doses have been administered at participating retail pharmacies.

While we continue to facilitate access to COVID-19 vaccines for all Americans, it is important to note that the Bridge Access Program is a temporary fix to longstanding barriers to adult vaccination, including lack of accessibility and availability of recommended adult vaccines. Moreover, the program is limited to COVID-19 vaccines.  CDC built the public health infrastructure for adult vaccination during the COVID-19 pandemic.  However, unless we are able to leverage and sustain the investments made to create this infrastructure, we will be in the same position we were in January 2020 the next time there is an outbreak of a vaccine-preventable disease.  Establishing a robust infrastructure through a Vaccines for Adults (VFA) program for uninsured adults, similar to what exists in the Vaccines for Children program, will support response readiness by reducing vaccination coverage disparities, improving outbreak control of vaccine-preventable diseases, and enhancing the infrastructure needed for rapidly responding to future pandemics.

VFA is an important step in building the most effective public health delivery system.  But we must also have a public health data system that is integrated with our health care system and our jurisdictional partners.

For example, with respect to fall respiratory data, CDC has improved sharing of respiratory virus data at the state level. Having this data available at the more granular jurisdictional level  is more useful for decision makers and communities.  Jurisdiction level data can be used to look at disease burden and spot the latest trends to facilitate public health planning and response efforts.  These data inform decision makers on how to best allocate critical resources, such as medical countermeasures and diagnostic tests, to areas with high disease burden and disproportionately affected populations. Additionally, having information about new disease trends at the jurisdictional level helps inform providers, neighboring jurisdictions, health care entities and the public on what to be vigilant for, and on any appropriate measures individuals can take to protect themselves.  CDC is working closely with our partners to improve access to some data at the jurisdictional level. However, absent new authority, there will continue to be limitations in the information CDC can collect and provide.

We have also been working swiftly to put into place forward-looking data use agreements (DUAs) with our state, local, tribal, and territorial partners to enable robust national situational awareness.  Specifically, we are introducing a common DUA to support more consistent reporting of data sources with our health department partners in the next month.  Consistent reporting allows CDC to compare data across states and jurisdictions and provide that information to decision makers at the local, state, and federal levels, enabling preparedness and response efforts for existing and emerging health threats.

CDC is using the data we do have to better help people make informed health decisions. CDC’s new Respiratory Virus Data Channel (RV Data Channel) provides updates on key respiratory virus illness findings from the past week.  The launch represents one step in a broader CDC data initiative to integrate timely information from CDC’s data systems that detect and monitor respiratory viruses and their health consequences.  The RV Data Channel is updated weekly and provides a new suite of data visualizations and interpretations that summarize viral respiratory illness data, present virus-specific findings, and include new ways to visualize and share timely respiratory virus data.  The channel will allow the public to find out how COVID-19, flu, or RSV may be spreading nationally or in their state.

While CDC is working hard with our partners to improve the collection and sharing of public health data, absent legislative action from Congress as proposed in the FY 2024 budget to address highly concerning limitations on the information CDC can attain and provide, without these additional authorities, the agency's ability to meet the public's and provide a complete national picture will be limited. There will continue to be an inconsistent patchwork of information used for public health and national security decision making.

Closing

CDC is committed to protecting Americans from emerging health threats through transparency, clear communication, and collaboration across government and with other public and private sector partners.  As demonstrated throughout this fall and winter respiratory season, we are taking important steps to protect your constituents, including providing information they need to better protect their health and the health of their loved ones.  Even as CDC takes concrete steps to achieve these goals, we know we can’t do this alone.  It will take continued collaboration from Congress to support an agency that is able to respond at a moment’s notice when we see threats to Americans’ health.  This means collaborating to build a stronger public health workforce at CDC and across the country.  It means supporting new legislation to get data to you, jurisdictions, and providers more quickly.  It also means investing in programs and capabilities to support quick access to vaccines for all adults, while enhancing CDC’s ability to detect a new emerging threat.  I look forward to working with you as we position CDC to continue being the leading public health agency in the world.

Endnotes

¹ Use of Updated COVID-19 Vaccines 2023–2024 Formula for Persons Aged ≥6 Months: Recommendations of the Advisory Committee on Immunization Practices — United States, September 2023 | MMWR cdc.gov