One-on-One With CDC’s Anne Schuchat

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: the CDC's COVID-19 incident response manager tells us how public health teams can prepare to get ahead of the virus through the summer and into the fall.

DR. ANNE SCHUCHAT:
I hope that we don't get complacent—that the worst is over and that everything was fine—because we don't have an all clear. The virus hasn't yet gone through the entire population, and we don't know whether the months ahead will bring a much worse illness.

I think we need to be ready for that. We need to have our systems even stronger than they've been in the past few months, and we need to take advantage of any break we get, now that the curve is flattening in many parts of the country, to be even more nimble going forward.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we are thinking about the future and what's next in the fight against the COVID-19 virus. For weary public health professionals, thinking now about another wave of infections later this year might seem impossible—especially given some states and territories have yet to reach their projected peak for new cases of infection.

But if you're able to begin planning, our guest tells us there are strategies that can help reduce stress on the healthcare system if a second wave of infections occurs as expected. The CDC's principal deputy director and COVID-19 incident response manager, Dr. Anne Schuchat, joins us to discuss those strategies and ways her agency can help.

How is the CDC working with the states on the response right now?

SCHUCHAT:
Well, CDC staff are working 24/7 to respond to this pandemic, and we are in lock step with state and local public health authorities. CDC was basically founded to support state and local public health, and we are working very closely with them.

Of course, the pandemic is unfolding in different ways in different jurisdictions. We try to make sure that we understand what's going on in the different jurisdictions and that we know what type of support and collaboration is best needed.

JOHNSON:
Is CDC responding to this crisis differently than it might for some other public health emergency, or is it the same?

SCHUCHAT:
We are using the systems that we always use when we have a national level emergency. We've activated our emergency operations center; we pretty much have thousands of CDC staff engaged. Of course, we have about 500 CDC staff embedded in the state and local health departments day in and day out, but we've deployed another 1500 or so for various different purposes.

We are using the systems and the capacities and the people, but this is a much larger emergency response than any that I've been involved in in my 32 years at the CDC.

We have had previous pandemics, we have had previous emerging infectious diseases, but this is a severe virus that's extremely transmissible and that is affecting essentially every jurisdiction. And we've never had an emerging infectious disease in the United States that led to the stay at home and shelter in place—the extensive community mitigation—that we're seeing in this response.

So, we know it's affecting every single American and it's affecting people in every country around the world.

JOHNSON:
And it's a moving target, right?

I mean, the story changes daily, depending on the data you're getting and what's happening in these communities and in peoples' homes.

How do you stay on top of that from the federal perspective?

SCHUCHAT:
I think it's very important, in emerging infectious diseases, to be nimble and to be ready. So, we had done lots of pandemic influenza preparedness training and, of course, in 2009, we and the nation responded to a pandemic of influenza.

But this virus is more challenging than the prior pandemics of influenza that, you know, the one that I was involved in, and, certainly, than the other emerging infectious diseases like SARS or MERS or Ebola, frankly. This virus can be spread by people who don't have symptoms at the time, so it's very transmissible; and the virus can be very severe, in particular in the elderly and people with underlying diseases, but also in others.

And so, the healthcare system overload that we saw in New York City or some other jurisdictions is the kind of thing we worry about when we prepare for pandemics and that we've had to deal with during this response. Protecting healthcare workers and critical infrastructure—always part of our plans, been very, very real in this one.

Now, of course, we're trying to make sure that we have the data in the very micro level—the small area level—that can help jurisdictions plan for potential reopenings—phased reopening. But making sure that there will have the capacity to understand the trajectories in their jurisdictions and to rapidly scale up contact tracing, case identification, cluster investigations, to be able to sustain the slowed spread and to prevent potential resurgences.

We know that this virus is serious and that most Americans haven't yet been infected. So, we're very vulnerable for additional infections, for continuation of the cases that we're seeing, and also for increasing resurgence in the future. So, a big challenge at every jurisdiction and for CDC, one that we are trying to fill the gaps for the state to help them with their hiring, help them with their surging of lab testing or contact tracing, and help them introduce innovation into the work that they're doing.

JOHNSON:
And each state has a different situation to deal with. Some, like New York, have been in the middle of this for a long time and are suffering greatly. Others seem to be barely touched by it.

How do you adjust what you do in your response to deal with those varying levels of involvement and crisis?

SCHUCHAT:
You know, there are two levels of challenge at the jurisdictional basis.

Now, there are the areas that haven't been that hard hit yet, or that haven't really been challenged yet; but there's also a huge range of capacity. So, some of the rural areas that haven't seen many cases yet have very limited ability to follow up—to do the case identification, lab, test, and contact tracing—and potentially their hospital capacity for critical care beds may be limited.

So, we've adapted some of our ongoing systems to really target in on this response. We have something called the National Healthcare Safety Network, the NHSN, which tracks antibiotic resistance and healthcare-associated infections. It's tracking hospital capacity so that we have, I think, more than half of the acute care hospitals in the nation reporting in to tell us about their intensive care unit beds, their ventilator beds, their healthcare worker staffing, the illness that they're seeing.

We've adapted our flu surveillance so that we can learn about small area trends and patterns with COVID-19. But we know that the cultures, the communities, the social networks in different states and localities are different, and what's acceptable in one place in terms of social distancing might be experiencing a lot of pushback in others. So, we're really trying to support the states and locals and get the resources that they need matched to what's available.

JOHNSON:
I think the nation was a little bit freaked out, frankly, about this idea that this might come back stronger in the winter—that's the conversation we're having right now.

What do public health agencies and jurisdictions need to do to be able to get ready for that? How does that planning work?

SCHUCHAT:
One thing we haven't talked that much about, which I really want people to think about, is influenza planning, because none of us know what's going to happen with COVID-19, but there pretty much hasn't been a year where there wasn't a flu season. And influenza vaccines are being produced right now, and states and clinicians are ordering them up.

The more people that get vaccinated against influenza, the less influenza we are going to have to deal with next year. Many winters, influenza and pneumonia that can be a follow on to influenza, fill up the hospital beds, and we really want as few people with influenza filling up those hospital beds in case we need to have those beds available for COVID-19. So, that's a planning-preparedness thing that people can do right now.

Of course, for those who dodged the bullet and didn't overwhelm their healthcare system with this round so far of the COVID-19, they have more time to plan to make sure that the training of their healthcare workers, the alternative care sites should they need them, the management of their bed capacity, their ventilators and their intensive care units, and their public health system is ready.

So, we know that it's difficult to do contact tracing for large numbers of people, and we really think that detecting cases quickly and identifying their contacts and having their contacts stay home is going to be really important. So, pretty much practicing that over the weeks and months ahead, before the fall season where there's a lot more respiratory illness, is an important thing that the states and locals can be doing now.

Mapping out their laboratory capacity and figuring out how to increase it so that more people can be tested; and really focusing in on their hotspots—whether it's a factory, a meat packing plant, which we know a lot of the states are dealing with, or a homeless population, or a prisoner jail population—getting a handle on how to prevent transmission and those types of congregate settings and detect illness early if it does emerge.

Those are the things that states can do today to get ready for what may or may not happen in terms of a surge in COVID-19.

JOHNSON:
Does the flu shot campaign, then, start earlier this year than normal?

Normally it's in the fall, right?

SCHUCHAT:
Well, usually the first doses become available in late summer. And so, I think we don't know exactly what the healthcare system will look like by, you know, August, September. We know now a lot of the outpatient clinics closed and urgent care was doing different things than usual.

I think it's an important time to have some contingency plans. Will the private sector be administering vaccines the way they usually do? Are the pharmacies set up to do what they do? Will we be not able to administer flu vaccine in doctor's offices? Are there ways that we can scale up the flu vaccination of adults, which usually lags behind what we do in children?

So, I think there's those kinds of planning, which involved public health and the private healthcare system really connecting and talking.

JOHNSON:
You've done a great job in such a short period of time, here in this conversation, summarizing a variety of steps that public health leaders can take around the country, but have we left anything out?

Are there any other viral suppression methods, or tactics, or procedures they should be thinking about right now that will get them ready for the next wave?

SCHUCHAT:
There's been lots of interest and innovation around contact tracing. And so, traditionally, the public health departments and staff identify a case—whether it's tuberculosis or it's meningitis—and they identify who was in close contact with that person and may need to be evaluated.

With COVID-19, the respiratory spread is so contagious that the challenges of contact tracing involve scale and speed. And so, innovative technologies may assist the local or state health department with that task. And we're really encouraging local and state health departments to hire more people—they can be temporary folks like call center staff that are laid off from their usual job, or Peace Corps volunteers, or census takers—and CDC's foundation is helping identify some short-term individuals to be hired to local or state health departments.

We're encouraging the state and locals to not just to more people, but also explore technology and see whether one of the apps or one of the other innovative technologies might work in their jurisdictions.

Something that would work in Kentucky may not work in New York City, but we think that there's been a good experience in some other countries with the use of innovative apps or technology to rapidly find contacts, and follow them up, and make sure that they get information about risk to them and about the need to stay home if they have been exposed.

So, I think that's the thing that the health departments, I encourage them to do. CDC is working very closely with the jurisdictions around the country in support of that effort. But, since I'm talking to you, it's a good time to mention it.

JOHNSON:
And the CDC is available, as you just said, to help states navigate those long lists of options and find the ones that might work best for their population.

SCHUCHAT:
That's right. We've set up technical assistance teams and we've actually deployed folks to dozens of states for different purposes, but we're beginning to deploy right now to assist with this enhanced contact tracing effort.

JOHNSON:
Some people have said, as this has rolled out over the last several months, that the CDC hasn't been as out front as maybe they thought it should be.

How do you address that?

SCHUCHAT:
I'm so sorry for that perception, and I can tell you that we have issued dozens of guidances and our website has had—I think we just crossed a billion views, I believe.

But one thing to say, though, is that we want to be the most trusted source of information for the public, and we want to provide the assistance that state and local public health needs.

A recent poll suggested that we were the site that the American public trusts the most. Part of that is because we want to be first, but we want to be right, and we want to retain our credibility. So, sometimes we're not the first people out there with advice or assessment or a tool, but we're really trying to get it right when we do put things out there.

This is a national emergency and coordinated, consistent communication is vital for that. And so, the lead for communication has not been the CDC for this response. The lead is coming from the White House, the Vice President's task force, and they are speaking for one voice. CDC is providing 24/7 technical assistance, and guidance, and messaging, and, often, the data behind what is coming out.

But we appreciate the chance to work directly with state and local public health, and the trusted voices in most communities are the local ones—whether it's the mayor or governor, or the health officer at that front line. So, we really want to be in support of those of you out there on the front line with the best information and tools that can help you do your jobs.

JOHNSON:
And my sense is that if any of those state departments were asked this very same question, they would say exactly that: that you're there with them helping them get this job done, because it is not a job that anyone can do on their own.

SCHUCHAT:
That's right. We're all in this together: public and private; state, local, federal, tribal. You know, we're doing calls virtually every day with thousands of folks, whether they are from public health, different sectors, or from partner groups or private sector, clinicians and so forth.

For us, it's not really about the spotlight. It's about what's needed. And so, I'm absolutely fine—if the right information is getting out there—for somebody else to be giving it. I just want to make sure the right information is available.

JOHNSON:
You've said earlier in this conversation that you've never seen anything like this in your long career in public health.

What is it that worries you most as you close out each day? What keeps you up at night?

SCHUCHAT:
You know, if you'd asked me six months ago what worries me the most, I would have said a pandemic of influenza or a similar virus; and that it has been my response for more than a decade.

Because we're having a pandemic of a severe respiratory virus, I think one thing that I worry about is complacency.

I've been so heartened by the individuals across the country taking this seriously, taking action, really trying to protect themselves and their family, and being, you know, extremely cooperative and collaborative.

I hope that we don't get complacent—that the worst is over and that everything was fine—because we don't have an all clear. The virus hasn't yet gone through the entire population, and we don't know whether the months ahead will bring a much worse illness.

I think we need to be ready for that. We need to have our systems even stronger than they've been in the past few months, and we need to take advantage of any break we get, now that the curve is flattening in many parts of the country, to be even more nimble going forward.

So, I think that health department staff, physicians, the public, the media, everybody's tired of this. We all want it to be over. It's not over.

JOHNSON:
Final question has to do with your advice for state health directors, state health teams, people in the public health trenches.

What's your best advice for them here in mid-April?

SCHUCHAT:
The first thing I would say is thank you, that the jobs that you had been doing are extraordinarily difficult. There's never enough information for the decisions that you're needing to make and, regardless of the resources, there's never enough to do what you really need to do. So, thank you.

I want to encourage you to really support each other as a peer network and to support your teams because you really are the front line keeping your communities healthy and safe. Obviously, public health is working closely with the healthcare community closely with other sectors, but this is a public health emergency and your expertise and stamina are essential.

So, hang in there, thank you, and really keep an attention to the resilience and the morale of your teams, because it is a marathon and we're really not even close to finished with it.

So, the major message I would have is thanks, not advice.

The other thing I would say is let us know where CDC can do better because we're a learning organization. We're committed to supporting you, providing you the best technical assistance and resources that we can; and I know a lot of you are not shy, but tell us when we can do better.

JOHNSON:
You can find links to the resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.