Preparing for the Next Pandemic: Lessons Learned and the Path Forward

Preparing for the Next Pandemic: Lessons Learned and the Path Forward

CDC Congressional Testimony

Select Subcommittee on the Coronavirus Pandemic, Committee on Oversight and Accountability, U.S. House of Representatives

Witness: Henry Walke, MD, MPH, Director, CDC Office of Readiness and Response

Introduction

Chairman Wenstrup, Ranking Member Ruiz, and distinguished members of the Subcommittee, it is an honor to appear before you today on behalf of the U.S. Department of Health and Human Services’ (HHS) Centers for Disease Control and Prevention (CDC).

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.

It has been nearly five years since we faced one of the greatest public health emergencies 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 disease threat facing our nation. We are seeing more infectious disease threats than ever before, including emerging pathogens like avian influenza and global outbreaks of highly concerning viruses like Marburg. At the same time, many of the leading causes of death for Americans are non-infectious diseases such as heart disease, stroke, substance use disorder (overdose) and suicide. We need a CDC that is trusted and has the tools to quickly and effectively respond to any public health threat.

The public health response to the COVID-19 pandemic highlighted a number of successes in responding to public health threats, but it also exposed challenges and gaps in CDC’s core capabilities that led our agency to conduct an extensive review to identify lessons learned and make changes in our organizational structure, systems, and processes. CDC has done the hard work to make improvements to our operations, processes, and communications. We have broken down internal silos, are working to develop and maintain stronger partnerships across the public health sector, and continue to adhere to a renewed focus on fast, accurate, and transparent communication to improve public trust. These advancements have strengthened our ability to deliver on our core mission to equitably protect the health, safety, and security of Americans. We are forging ahead as “One CDC,” working as a more cohesive, disease-agnostic entity.

To continue to tackle this diverse set of public health challenges, as well as new and emerging threats, CDC needs help from Congress through sustained and increased resources and authorities as requested in the President’s Budget, that support public health’s core capabilities, including data and analytics, laboratory capacity, domestic and global readiness and response, and a diverse public health workforce. These core capabilities underscore everything we do at CDC and are the foundation for public health work completed by state, local, tribal, and territorial partners, as well as nongovernmental and private sector partners in the United States and around the world.

World-Class Data and Analytics

CDC is supporting better, faster, actionable data for decision-making at all levels of public health. Our vision is to create a unified public health community that engages with the healthcare and private sectors, communicates clearly with the public to equip individuals with the information needed to support their health, and supports communities with relevant data to protect health and improve lives.

Thanks to support from Congress, CDC has made investments in modernizing public health and healthcare data and is moving toward a more secure, interoperable health data infrastructure. We continue to identify novel data sources and strengthen mission-critical data sources, such as electronic case reporting, syndromic surveillance, electronic laboratory reporting, vital statistics, and hospitalization data. These data are used to detect, understand, and respond to the full spectrum of health conditions.

For example, CDC’s Respiratory Illnesses Data Channel provides COVID-19, flu, and respiratory syncytial virus (RSV) data from a variety of sources to inform the public about the status and trends of viruses that cause respiratory illnesses. CDC collects, compiles, analyzes, and shares these data from multiple sources of surveillance data and provides expert analysis of what the data mean nationally. This season CDC added a “community snapshot” to the Data Channel, which allows people to select a state and county to receive updated local information on respiratory viruses in their area. The channel also provides links to further information on immunizations and CDC’s current respiratory guidance.

Public health entities must be able to rapidly share data within and among jurisdictions, and with CDC, to enable local and federal leaders to make the best decisions for their communities and save lives in dynamic situations while safeguarding the privacy of Americans.

To further advance this effort, in October 2024, CDC launched the “One CDC” Data Platform (1CDP). 1CDP leverages data across the entire agency as one team. The goal of 1CDP is to improve programmatic, scientific, and response work using proven technology, common tools, and shared data assets that enable programs and public health experts to act on data to improve health and help save lives. With centralized data across CDC’s centers, CDC can efficiently manage daily tasks and swiftly scale operations to meet evolving needs. This platform sets a foundation for CDC data throughout the agency and builds on CDC’s Response Ready Enterprise Data Integration platform (RREDI). RREDI pulls data from state, local, tribal, and territorial partners and other sources into one common operating picture and enables HHS, other response leaders, and public health partners to analyze, visualize, and share that data in real-time during a public health response.

To make the most of these data sources, CDC also needs to continue to innovate and expand its analytical abilities. We are doing this by generating forecasts and scenario models in our Center for Forecasting and Outbreak Analytics (CFA) to extract as much information as possible from the available data. These forecasts and models deliver actionable analyses to guide decision makers at all levels of government. For example, CFA recently assessed the risk posed by the Marburg virus outbreak in the Republic of Rwanda to the United States general population during the next three months and found the risk to the general U.S. population to be low, with moderate confidence. This assessment informs U.S. preparedness efforts and relied on subject-matter experts evaluating a range of evidence related to risk, including epidemiologic data from the outbreak in Rwanda and historical data on Marburg virus epidemiology and clinical severity.

State-of-the-Art Laboratory Capacity

CDC’s scientists are working in laboratories across the United States, from Anchorage to San Juan, and are in countries around the world, building capacity for the prevention and control of diseases domestically and abroad. Laboratories are an essential part of our core public health infrastructure. They are often the first to detect, identify, and respond to health threats. Modern, high-performing laboratories prepare us to detect emerging threats and react quickly in emergencies.

State-of-the-art laboratory capacity requires consistent attention and investment across all laboratory systems—quality, safety, informatics, workforce, and response readiness. A high-functioning and effective national laboratory system includes CDC working closely with state and local public health entities as well as clinical laboratory companies and is critical to providing timely and actionable data to protect public health, particularly at the onset of emergency responses and testing surges.

Taking lessons learned from COVID-19, CDC has implemented extensive quality control measures internally and expanded partnerships to support development and distribution of tests.

In September 2024, CDC made the first-of-its-kind awards to create “warm bases” with five clinical laboratory companies. These public-private partnerships are unprecedented for CDC and represent a significant shift in how we work with the private sector for public benefit. CDC will be able to engage these companies along three lines of laboratory response: test design, surge testing, and test payment. Already, these laboratories have started test development for H5N1, and CDC recently awarded funding to three clinical laboratory companies for the development of Oropouche diagnostics. This means companies will be developing new tests for public health response alongside CDC. With funding, this arrangement is intended to help move testing to clinical laboratory companies, where most people get tested, with the ability to scale up quickly and early rather than in the midst of an emergency.

Domestic and Global Preparedness and Response

CDC is a national security asset, advancing the health and safety of Americans by preparing for and responding to outbreaks where and when they start. Leveraging the public health workforce, lab capabilities, and data analytics, CDC must be operationally response-ready to monitor, respond to, and address global and domestic threats.

When it takes less than 36 hours for an outbreak to spread from a remote village to any major city in the world, protecting U.S. health and national security means making sure other countries have the knowledge and the resources to stop threats before they can spread beyond their borders. Together, we must build these first lines of defense to better prevent, detect, and respond to disease and other biothreats.

For example, the Democratic Republic of the Congo (DRC) has experienced the highest number of mpox cases on record in the last two years with cases in neighboring countries and travel-associated cases in several other countries. It is critical for the U.S. government (USG) to both respond to this outbreak globally and prepare to rapidly detect, test, and manage cases in the United States, should they occur. The clade 1 mpox response utilized the USG’s Playbook for Biological Incident Response to support a standard operational response structure for international and domestic interagency response teams with clear roles, responsibilities and timelines. The USG team stood up within 24 hours, and lines of effort included DRC response, regional preparedness, medical countermeasures, domestic preparedness and diplomatic coordination. The structure provides a common operating picture across the USG and agreed-upon priorities; a centralized space for U.S. missions and our partners for information and support from across the USG (lab supplies, technical assistance, or talking points); streamlined reporting across the federal government and enhanced ability to speak with one voice to our external partners; and creates a team approach.

Similarly, our response to the current Marburg outbreak in Rwanda is building on decades of collaboration in-country to build capacity globally to combat infectious disease. CDC experts in Rwanda are providing direct technical support to governmental, multilateral, and non-governmental public health partners—supporting surveillance, contact tracing, infection prevention and control, laboratory preparedness (including biosafety and biosecurity), and support for a survivor program to prevent survivors from re-igniting subsequent outbreaks.

Domestically, CDC is also preparing and responding to fall/winter respiratory season. Even a mild or moderate season now is worse than most severe seasons before the pandemic. With COVID on top of flu, RSV, and the other respiratory viruses, we now have more illness, more hospitalizations, and more deaths. CDC is preparing for the season by bringing together experts from across disciplines and across the agency to provide clear information and current data to drive action. We are improving how we collect and share key disease data by bringing together multiple data sources, such as emergency department visits, test positivity, wastewater surveillance, hospitalizations, deaths, and vaccine uptake, into our Respiratory Illness Data Channel. As the season progresses, we will be collecting and analyzing vaccine effectiveness data which informs our vaccination guidance, decisions on vaccine production, and vaccine purchases. We continue to meet regularly with vaccine manufacturers and distributors in coordination with the Food and Drug Administration and the Administration for Strategic Preparedness and Response within HHS to ensure sufficient supply of vaccine especially for key groups like long-term care facilities and pediatrician’s offices. Further, we continue to engage and educate healthcare providers to improve implementation of vaccines and treatments.

Increased and sustained investments, along with updated authorities, that support core capabilities set the foundation for how CDC and our public health partners prepare for and respond to any public health challenge or priority.

Diverse Public Health Workforce

A robust workforce at the federal, state, and local levels is essential to efficiently and effectively deliver services to meet the public health needs in communities across the United States and be ready to respond to emergencies. The public health workforce supports the health of all Americans by investigating outbreaks, sampling wastewater, testing laboratory samples, and more.

The infrastructure needs in health departments are substantial—many public health agencies lack resources to support foundational capacities such as operations, communications, and emergency preparedness, which are the building blocks of any response. To be ready for any biothreat, the public health system in the United States requires a robust and nimble public health infrastructure and a skilled public health workforce ready to respond to emergencies.

CDC is building a diverse workforce at every level and every point of entry that reflects the sectors and communities we serve. Our work focuses on hiring, training, and retaining public health workers to meet the unique needs of each community.

Internally, our new agency-wide CDCReady Responder program helps ensure that our multidisciplinary workforce is enrolled and trained for core functions of a response before a public health event and is ready to respond when and where needed. We need the entire agency to be able to respond to any health threat that comes our way. We are currently managing six emergency responses, including Marburg, Dengue/Oropouche, and Hurricane Helene, that involve more than 800 staff. CDC has been able to respond more efficiently in part because the majority of response staff are currently enrolled in CDCReady Responder. An ability to surge staff and to respond to public health emergencies faster than ever before represents a significant improvement over how CDC operated prior to the COVID-19 emergency and is a key example of how CDC is breaking down silos, leveraging and surging our public health workforce, and prioritizing readiness and response.

Beyond Infectious Disease Preparedness

Preparing for infectious disease outbreaks is crucial to protecting the lives of Americans. However, the nation faces additional health crises from environmental disasters. CDC works to protect people’s physical and mental health during such events through response and recovery efforts. Working with other federal agencies, states, territories, tribes, local jurisdictions, and other partners, CDC provides expertise to help protect people from a range of environmental health threats, including flooding, wildfires, and chemical spills.

During the recent response to Hurricanes Helene and Milton, more than 60 staff from across CDC and the Agency for Toxic Substances and Disease Registry (ATSDR) provided guidance to the states on a wide range of issues that impacted the communities on the ground. CDC and ATSDR personnel assisted jurisdictions in efforts to address food and waterborne illness prevention, generator safety and carbon monoxide poisoning prevention, first responder safety, the impact of potential mold exposure on health, post-flood safety and clean up after the storm, guidance on infection control practices in healthcare settings experiencing infrastructure disruptions, and mosquito control practices to prevent the spread of vector-borne illness. In addition, during the 2023 East Palestine train derailment and subsequent chemical spill, CDC and ATSDR led federal public health efforts to assess and prevent health impacts of chemical exposure. More than 80 staff were involved in the response with approximately 20 staff deployed on-site, and more than 60 staff analyzing data for potential health impacts, conducting a public health needs assessment for the community to guide response efforts, and working with federal, state, and local partners to communicate health information to residents and local healthcare clinicians. CDC and ATSDR also provide jurisdictions with information and tools prior to environmental health emergencies to help with preparedness efforts, such as identifying populations most at-risk during an environmental emergency.

Looking Forward

As we look to the future, it is critical that we are able to build upon and strengthen the public health infrastructure and systems developed during the COVID-19 pandemic response. As COVID-19 supplemental resources wane and the nation turns to focus on other challenges, Congress’s support is vital to continue to use lessons learned to find solutions. The requested increased and sustained investment from Congress, as well as new authorities, will enable CDC to continue its life-saving work more efficiently and effectively in the future.

Vaccines for Adults

As an example of the need for additional investment and authority, during COVID-19, supplemental resources enabled the distribution and administration of free COVID-19 vaccines. As the public health emergency ended, CDC launched the Bridge Access Program in September 2023 to continue providing no-cost COVID-19 vaccines to eligible uninsured and underinsured adults from select pharmacy chains, local public health providers, and health centers. The Bridge Access Program was intended to serve as a temporary solution to support COVID-19 vaccine access until a Vaccines for Adults (VFA) program is created by Congress.

Unfortunately, due to the rescission of COVID supplemental funding enacted in the Fiscal Responsibility Act of 2023 and the Consolidated Appropriations Act, 2024, the Bridge Access Program ended early in August 2024. Now, there is no central system in the United States that supports streamlined and efficient access to vaccines for adults. The Administration has proposed the VFA program to: 1) support routine vaccination for uninsured adults in the United States; and 2) create a warm base for future vaccine administration in the event of another widespread threat. Having a VFA program already in place will prevent CDC from having to build infrastructure from scratch when a new threat emerges. With a VFA program, public health entities will be able to more efficiently administer future vaccines, whether as routine, outbreak, or pandemic related immunizations.

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. Likewise, our jurisdictions will find themselves without this infrastructure when there is an outbreak of any vaccine-preventable disease affecting adults. Establishing a robust infrastructure through a VFA program for uninsured adults 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.

Data Authority

Another key element to CDC’s preparedness and response priority in need of additional authority is improving public health data capabilities at the federal, state, local, tribal, and territorial levels. Data powers our nation’s ability to detect and respond to health threats, and each outbreak underscores a critical need to strengthen our nation’s capabilities for early warning of disease threats and real-time situational awareness of public health problems.

We have already made great progress. For example, as of October 2024, more than 45,800 healthcare facilities across all 50 states are delivering automated, real-time, electronic case reports—up from only 187 before the COVID-19 pandemic. And more than 80 percent of hospital emergency departments now provide syndromic surveillance data to CDC.

However, there is more work to do. Despite the progress made, 86 percent of providers still use some form of manual reporting to share information with health departments, and only approximately 20 percent of providers use electronic case reporting. Updating CDC’s data policy levers will support CDC and the nation in having better real-time situational awareness for the next potential threat.

Wastewater Surveillance

CDC is also leveraging wastewater surveillance to support federal, state, and local public health entities in rapidly detecting infectious diseases spreading in their communities. 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 we do not have sufficient clinical data. Health departments, community leaders, and individuals can use this information to make decisions on public health actions to protect their community. For example, CDC and state and local public health authorities are monitoring wastewater data for evidence of high influenza A virus levels in sites around the nation. CDC is actively looking at multiple flu indicators, including the detection of the influenza A (H5) subtype, to look for indications of further virus spread. CDC also uses wastewater data as one part of our Traveler-based Genomic Surveillance program, a public-private partnership that anonymously monitors for infectious disease threats in international travelers at nine sentinel airports. CDC’s wastewater surveillance program is currently supported solely through COVID-19 supplemental funding. These activities have been pivotal in ensuring that our states and communities have the best possible guidance and data to inform public health action and they will end without additional base funding.

CDC has invested more than $500 million in supplemental funding to build flexible and nimble wastewater surveillance testing capacity. Currently, CDC receives wastewater data from approximately 1,500 sampling sites, representing about 140 million Americans in all 50 states. For CDC to continue this critical capability, it will take additional resources from Congress. The President’s Budget requests $20 million for wastewater surveillance, which will allow the agency to support a limited number of states for wastewater surveillance.

CDC is grateful for supplemental appropriations to address recent public health emergencies. We have been able to use these funds to support critical activities, including national programs for wastewater surveillance and genomic sequencing. However, supplemental funding is no longer available and without an annual appropriation, these programs will end or scale back substantially in the coming year. Lack of support for these critical efforts threatens to erase the progress we made over the past few years and will leave the public health system less prepared to face future disease threats.

Conclusion

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. 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 cannot 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.

Supplemental funding in an emergency is always critical for responding to urgent needs but is emblematic of the historic trend to fund public health needs only when there are dire, high-profile challenges, creating a boom-or-bust cycle with steep fiscal cliffs that require jurisdictions to dismantle programs the public has come to expect, only to scramble to restart them for the next emergency. Notably, continuity of investment in public health extends beyond CDC as it is just as vital for state and local jurisdictions. Approximately 80 percent of CDC’s domestic funding goes to state and local health departments. A lack of sustained funding means the CDC, state, and local public health partners cannot effectively plan and respond to future threats.

I look forward to working with you as we position CDC to continue being the leading public health agency in the world.