Centers for Disease Control and Prevention

Establishment

The Communicable Disease Center was founded July 1, 1946, as the successor to the World War II Malaria Control in War Areas program^[7] of the Office of National Defense Malaria Control Activities.^[8]

Preceding its founding, organizations with global influence in malaria control were the Malaria Commission of the League of Nations and the Rockefeller Foundation.^[9] The Rockefeller Foundation greatly supported malaria control,^[9] sought to have the governments take over some of its efforts, and collaborated with the agency.^[10]

The new agency was a branch of the U.S. Public Health Service and Atlanta was chosen as the location because malaria was endemic in the Southern United States.^[11] The agency changed names (see infobox on top) before adopting the name Communicable Disease Center in 1946. Offices were located on the sixth floor of the Volunteer Building on Peachtree Street.^[12]

With a budget at the time of about $1 million, 59 percent of its personnel were engaged in mosquito abatement and habitat control with the objective of control and eradication of malaria in the United States^[13] (see National Malaria Eradication Program).

Among its 369 employees, the main jobs at CDC were originally entomology and engineering. In CDC's initial years, more than six and a half million homes were sprayed, mostly with DDT. In 1946, there were only seven medical officers on duty and an early organization chart was drawn. Under Joseph Walter Mountin, the CDC continued to be an advocate for public health issues and pushed to extend its responsibilities to many other communicable diseases.^[14]

In 1947, the CDC made a token payment of $10 to Emory University for 15 acres (61,000 m²) of land on Clifton Road in DeKalb County, still the home of CDC headquarters as of 2019. CDC employees collected the money to make the purchase. The benefactor behind the "gift" was Robert W. Woodruff, chairman of the board of The Coca-Cola Company. Woodruff had a long-time interest in malaria control, which had been a problem in areas where he went hunting. The same year, the PHS transferred its San Francisco based plague laboratory into the CDC as the Epidemiology Division, and a new Veterinary Diseases Division was established.^[7]

Growth

In 1951, Chief Epidemiologist Alexander Langmuir's warnings of potential biological warfare during the Korean War spurred the creation of the Epidemic Intelligence Service (EIS) as a two-year postgraduate training program in epidemiology. The success of the EIS program led to the launch of Field Epidemiology Training Programs (FETP) in 1980, training more than 18,000 disease detectives in over 80 countries.^[15] In 2020, FETP celebrated the 40th anniversary of the CDC's support for Thailand's Field Epidemiology Training Program. Thailand was the first FETP site created outside of North America and is found in numerous countries, reflecting CDC's influence in promoting this model internationally.^[16] The Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET) has graduated 950 students.^[17]

The mission of the CDC expanded beyond its original focus on malaria to include sexually transmitted diseases when the Venereal Disease Division of the U.S. Public Health Service (PHS) was transferred to the CDC in 1957. Shortly thereafter, Tuberculosis Control was transferred (in 1960) to the CDC from PHS, and then in 1963 the Immunization program was established.^[18]

It became the National Communicable Disease Center effective July 1, 1967, and the Center for Disease Control on June 24, 1970. At the end of the Public Health Service reorganizations of 1966–1973, it was promoted to being a principal operating agency of PHS.^[8]

Recent history

It was renamed to the plural Centers for Disease Control effective October 14, 1980,^[8] as the modern organization of having multiple constituent centers was established. By 1990, it had four centers formed in the 1980s: the Center for Infectious Diseases, Center for Chronic Disease Prevention and Health Promotion, the Center for Environmental Health and Injury Control, and the Center for Prevention Services; as well as two centers that had been absorbed by CDC from outside: the National Institute for Occupational Safety and Health in 1973, and the National Center for Health Statistics in 1987.^[19]

An act of the United States Congress appended the words "and Prevention" to the name effective October 27, 1992. However, Congress directed that the initialism CDC be retained because of its name recognition.^[20] Since the 1990s, the CDC focus has broadened to include chronic diseases, disabilities, injury control, workplace hazards, environmental health threats, and terrorism preparedness. CDC combats emerging diseases and other health risks, including birth defects, West Nile virus, obesity, avian, swine, and pandemic flu, E. coli, and bioterrorism, to name a few. The organization would also prove to be an important factor in preventing the abuse of penicillin. In May 1994 the CDC admitted having sent samples of communicable diseases to the Iraqi government from 1984 through 1989 which were subsequently repurposed for biological warfare, including Botulinum toxin, West Nile virus, Yersinia pestis and Dengue fever virus.^[21]

On April 21, 2005, then–CDC Director Julie Gerberding formally announced the reorganization of CDC to "confront the challenges of 21st-century health threats".^[22] She established four Coordinating Centers. In 2009 the Obama administration re-evaluated this change and ordered them cut as an unnecessary management layer.^[23]

As of 2013, the CDC's Biosafety Level 4 laboratories were among the few that exist in the world.^[24] They included one of only two official repositories of smallpox in the world, with the other one located at the State Research Center of Virology and Biotechnology VECTOR in the Russian Federation. In 2014, the CDC revealed they had discovered several misplaced smallpox samples while their lab workers were "potentially infected" with anthrax.^[25]

The city of Atlanta annexed the property of the CDC headquarters effective January 1, 2018, as a part of the city's largest annexation within a period of 65 years; the Atlanta City Council had voted to do so the prior December.^[3] The CDC and Emory University had requested that the Atlanta city government annex the area, paving the way for a MARTA expansion through the Emory campus, funded by city tax dollars.^[26] The headquarters were located in an unincorporated area,^[27] statistically in the Druid Hills census-designated place.^[28]

On August 17, 2022, Dr. Walensky said the CDC would make drastic changes in the wake of mistakes during the COVID-19 pandemic. She outlined an overhaul of how the CDC would analyze and share data and how they would communicate information to the general public. In her statement to all CDC employees, she said: "For 75 years, CDC and public health have been preparing for COVID-19, and in our big moment, our performance did not reliably meet expectations."^[29] Based on the findings of an internal report, Walensky concluded that "The CDC must refocus itself on public health needs, respond much faster to emergencies and outbreaks of disease, and provide information in a way that ordinary people and state and local health authorities can understand and put to use" (as summarized by the New York Times).^[30]

Locations

Most CDC centers are located in Atlanta. Building 18, which opened in 2005 at the CDC's main Roybal campus (named in honor of the late Representative Edward R. Roybal), contains the premier BSL4 laboratory in the United States.^[34][35][36]

A few of the centers are based in or operate other domestic locations:^[37]

• The National Center for Health Statistics is primarily located in Hyattsville, Maryland, with a branch in Research Triangle Park in North Carolina.
• The National Institute for Occupational Safety and Health's primary locations are Cincinnati; Morgantown, West Virginia; Pittsburgh; Spokane, Washington; and Washington, D.C., with branches in Denver; Anchorage, Alaska; and Atlanta.
• The CDC Washington Office is based in Washington, D.C.
• Two divisions of the National Center for Emerging and Zoonotic Infectious Diseases are based outside Atlanta. The Division of Vector-Borne Diseases is based in Fort Collins, Colorado, with a branch in San Juan, Puerto Rico. The Arctic Investigations Program is based in Anchorage.

In addition, CDC operates quarantine facilities in 20 cities in the U.S.^[38]

Epidemic Intelligence Service (EIS)

The Epidemic Intelligence Service (EIS) is composed of "boots-on-the-ground disease detectives" who investigate public health problems domestically and globally.^[42] When called upon by a governmental body, EIS officers may embark on short-term epidemiological assistance assignments, or "Epi-Aids", to provide technical expertise in containing and investigating disease outbreaks.^[43][44][45] The EIS program is a model for the international Field Epidemiology Training Program.

Public Health Associates Program

The CDC also operates the Public Health Associate Program (PHAP), a two-year paid fellowship for recent college graduates to work in public health agencies all over the United States. PHAP was founded in 2007 and currently^[when?] has 159 associates in 34 states.^[46]

Communicable diseases

The CDC's programs address more than 400 diseases, health threats, and conditions that are major causes of death, disease, and disability. The CDC's website has information on various infectious (and noninfectious) diseases, including smallpox, measles, and others.

Division of Select Agents and Toxins

Within the division are two programs: the Federal Select Agent Program (FSAP) and the Import Permit Program. The FSAP is run jointly with an office within the U.S. Department of Agriculture, regulating agents that can cause disease in humans, animals, and plants. The Import Permit Program regulates the importation of "infectious biological materials."^[67]

The CDC runs a program that protects the public from rare and dangerous substances such as anthrax and the Ebola virus. The program, called the Federal Select Agent Program, calls for inspections of labs in the U.S. that work with dangerous pathogens.^[68]

During the 2014 Ebola outbreak in West Africa, the CDC helped coordinate the return of two infected American aid workers for treatment at Emory University Hospital, the home of a special unit to handle highly infectious diseases.^[69]

As a response to the 2014 Ebola outbreak, Congress passed a Continuing Appropriations Resolution allocating $30,000,000 towards CDC's efforts to fight the virus.^[70]

Non-communicable diseases

The CDC also works on non-communicable diseases, including chronic diseases caused by obesity, physical inactivity and tobacco-use.^[71] The work of the Division for Cancer Prevention and Control, led from 2010 by Lisa C. Richardson, is also within this remit.^[72][73]

Antibiotic resistance

The CDC implemented their National Action Plan for Combating Antibiotic Resistant Bacteria as a measure against the spread of antibiotic resistance in the United States. This initiative has a budget of $161 million and includes the development of the Antibiotic Resistance Lab Network.^[74]

Global health

Globally, the CDC works with other organizations to address global health challenges and contain disease threats at their source. They work with many international organizations such as the World Health Organization (WHO) as well as ministries of health and other groups on the front lines of outbreaks. The agency maintains staff in more than 60 countries, including some from the U.S. but more from the countries in which they operate.^[75] The agency's global divisions include the Division of Global HIV and TB (DGHT), the Division of Parasitic Diseases and Malaria (DPDM), the Division of Global Health Protection (DGHP), and the Global Immunization Division (GID).^[76]

The CDC has been working with the WHO to implement the International Health Regulations (IHR), an agreement between 196 countries to prevent, control, and report on the international spread of disease, through initiatives including the Global Disease Detection Program (GDD).^[77]

The CDC has also been involved in implementing the U.S. global health initiatives President's Emergency Plan for AIDS Relief (PEPFAR) and President's Malaria Initiative.^[78]

Travelers' health

The CDC collects and publishes health information for travelers in a comprehensive book, CDC Health Information for International Travel, which is commonly known as the "yellow book."^[79] The book is available online and in print as a new edition every other year and includes current travel health guidelines, vaccine recommendations, and information on specific travel destinations. The CDC also issues travel health notices on its website, consisting of three levels:

• "Watch": Level 1 (practice usual precautions)
• "Alert": Level 2 (practice enhanced precautions)
• "Warning": Level 3 (avoid nonessential travel)^[80]

Vaccine safety

The CDC uses a number of tools to monitor the safety of vaccines. The Vaccine Adverse Event Reporting System (VAERS), a national vaccine safety surveillance program run by CDC and the FDA. "VAERS detects possible safety issues with U.S. vaccines by collecting information about adverse events (possible side effects or health problems) after vaccination."^[81] The CDC's Safety Information by Vaccine page provides a list of the latest safety information, side effects, and answers to common questions about CDC recommended vaccines.^[82]

The Vaccine Safety Datalink (VSD) works with a network of healthcare organizations to share data on vaccine safety and adverse events.^[83] The Clinical Immunization Safety Assessment (CISA) project is a network of vaccine experts and health centers that research and assist the CDC in the area of vaccine safety.^[84]

CDC also runs a program called V-safe, a smartphone web application that allows COVID-19 vaccine recipients to be surveyed in detail about their health in response to getting the shot.^[85]

Activities

The Foundation engages in research projects and health programs in more than 160 countries every year, including in focus areas such as cardiovascular disease, cancer, emergency response, and infectious diseases, particularly HIV/AIDS, Ebola, rotavirus, and COVID-19.^[88]

• EmPOWERED Health Program: Launched in November 2019 with funding from Amgen, the program works to empower cancer patients to become actively involved in the decision making around their treatments.^[90][91]
• Fries Prize for Improving Health: An annual prize first awarded in 1992 that "recognizes an individual who has made major accomplishments in health improvement and with the general criteria of the greatest good for the greatest number".^[92]

Criticism

In 2015, BMJ associate editor Jeanne Lenzer raised concerns that the CDC's recommendations and publications may be influenced by donations received through the Foundation, which includes pharmaceutical companies.^[93]

Tuskegee study of untreated syphilis in Black men

For 15 years, the CDC had direct oversight over the Tuskegee syphilis experiment.^[94] In the study, which lasted from 1932 to 1972, a group of Black men (nearly 400 of whom had syphilis) were studied to learn more about the disease. The disease was left untreated in the men, who had not given their informed consent to serve as research subjects. The Tuskegee Study was initiated in 1932 by the Public Health Service, with the CDC taking over the Tuskegee Health Benefit Program in 1995.^[94]

Gun control

An area of partisan dispute related to CDC funding is studying firearms effectiveness. Although the CDC was one of the first government agencies to study gun related data, in 1996 the Dickey Amendment, passed with the support of the National Rifle Association of America, states "none of the funds available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control".^[95] Advocates for gun control oppose the amendment and have tried to overturn it.^[96]

Looking at the history of the passage of the Dickey Amendment, in 1992, Mark L. Rosenberg and five CDC colleagues founded the CDC's National Center for Injury Prevention and Control, with an annual budget of approximately $260,000. They focused on "identifying causes of firearm deaths, and methods to prevent them".^[97] Their first report, published in the New England Journal of Medicine in 1993 entitled "Guns are a Risk Factor for Homicide in the Home", reported "mere presence of a gun in a home increased the risk of a firearm-related death by 2.7 percent, and suicide fivefold – a "huge" increase."^[97] In response, the NRA launched a "campaign to shut down the Injury Center." Two conservative pro-gun groups, Doctors for Responsible Gun Ownership and Doctors for Integrity and Policy Research joined the pro-gun effort, and, by 1995, politicians also supported the pro-gun initiative. In 1996, Jay Dickey (R) Arkansas introduced the Dickey Amendment statement stating "none of the funds available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control" as a rider.^[95] in the 1996 appropriations bill."^[97] In 1997, "Congress re-directed all of the money for gun research to the study of traumatic brain injury."^[97] David Satcher, CDC head 1993–98^[98] advocated for firearms research.^[97] In 2016 over a dozen "public health insiders, including current and former CDC senior leaders" told The Trace interviewers that CDC senior leaders took a cautious stance in their interpretation of the Dickey Amendment and that they could do more but were afraid of political and personal retribution.^[97]

In 2013, the American Medical Association, the American Psychological Association, and the American Academy of Pediatrics sent a letter to the leaders of the Senate Appropriations Committee asking them "to support at least $10 million within the Centers for Disease Control and Prevention (CDC) in FY 2014 along with sufficient new taxes at the National Institutes of Health to support research into the causes and prevention of violence. Furthermore, we urge Members to oppose any efforts to reduce, eliminate, or condition CDC funding related to violence prevention research."^[99] Congress maintained the ban in subsequent budgets.^[96]

Ebola

In October 2014, the CDC gave a nurse with a fever who was later diagnosed with Ebola permission to board a commercial flight to Cleveland.^[100]

COVID-19

The CDC has been widely criticized for its handling of the COVID-19 pandemic. In 2022, CDC director Rochelle Walensky acknowledged "some pretty dramatic, pretty public mistakes, from testing to data to communications", based on the findings of an internal examination.^[30]

The first confirmed case of COVID-19 was discovered in the U.S. on January 20, 2020.^[101] However, widespread COVID-19 testing in the United States was effectively stalled until February 28, when federal officials revised a faulty CDC test, and days afterward, when the Food and Drug Administration began loosening rules that had restricted other labs from developing tests.^[102] In February 2020, as the CDC's early coronavirus test malfunctioned nationwide,^[103] CDC Director Robert R. Redfield reassured fellow officials on the White House Coronavirus Task Force that the problem would be quickly solved, according to White House officials. It took about three weeks to sort out the failed test kits, which may have been contaminated during their processing in a CDC lab. Later investigations by the FDA and the Department of Health and Human Services found that the CDC had violated its own protocols in developing its tests.^[103][104] In November 2020, NPR reported that an internal review document they obtained revealed that the CDC was aware that the first batch of tests which were issued in early January had a chance of being wrong 33 percent of the time, but they released them anyway.^[105]

In May 2020, The Atlantic reported that the CDC was conflating the results of two different types of coronavirus tests – tests that diagnose current coronavirus infections, and tests that measure whether someone has ever had the virus. The magazine said this distorted several important metrics, provided the country with an inaccurate picture of the state of the pandemic, and overstated the country's testing ability.^[106]

In July 2020, the Trump administration ordered hospitals to bypass the CDC and instead send all COVID-19 patient information to a database at the Department of Health and Human Services. Some health experts opposed the order and warned that the data might become politicized or withheld from the public.^[107] On July 15, the CDC alarmed health care groups by temporarily removing COVID-19 dashboards from its website. It restored the data a day later.^{[108][109][110]}

In August 2020, the CDC recommended that people showing no COVID-19 symptoms do not need testing. The new guidelines alarmed many public health experts.^[111] The guidelines were crafted by the White House Coronavirus Task Force without the sign-off of Anthony Fauci of the NIH.^[112][113] Objections by other experts at the CDC went unheard. Officials said that a CDC document in July arguing for "the importance of reopening schools" was also crafted outside the CDC.^[114] On August 16, the chief of staff, Kyle McGowan, and his deputy, Amanda Campbell, resigned from the agency.^[115] The testing guidelines were reversed on September 18, 2020, after public controversy.^[116]

In September 2020, the CDC drafted an order requiring masks on all public transportation in the United States, but the White House Coronavirus Task Force blocked the order, refusing to discuss it, according to two federal health officials.^[117]

In October 2020, it was disclosed that White House advisers had repeatedly altered the writings of CDC scientists about COVID-19, including recommendations on church choirs, social distancing in bars and restaurants, and summaries of public-health reports.^[118]

In the lead up to 2020 Thanksgiving, the CDC advised Americans not to travel for the holiday saying, "It's not a requirement. It's a recommendation for the American public to consider." The White House coronavirus task force had its first public briefing in months on that date but travel was not mentioned.^[119]

The New York Times later concluded that the CDC's decisions to "ben[d] to political pressure from the Trump White House to alter key public health guidance or withhold it from the public [...] cost it a measure of public trust that experts say it still has not recaptured" as of 2022.^[30]

In May 2021, following criticism by scientists, the CDC updated its COVID-19 guidance to acknowledge airborne transmission of COVID-19, after having previously claimed that the majority of infections occurred via "close contact, not airborne transmission".^[120]

In December 2021, following a request from the CEO of Delta Air Lines, CDC shortened its recommended isolation period for asymptomatic individuals infected with COVID-19 from 10 days to five.^{[121][122][123]}

Until 2022, the CDC withheld critical data about COVID-19 vaccine boosters, hospitalizations and wastewater data.^[124]

On June 10, 2022, the Biden Administration ordered the CDC to remove the COVID-19 testing requirement for air travelers entering the United States.^[125]

In January 2022, it was revealed that the CDC had communicated with moderators at Facebook and Instagram over COVID-19 information and discussion on the platforms, including information that the CDC considered false or misleading and that might influence people not to get the COVID-19 vaccines.^[126]

Zombie Apocalypse campaign

On May 16, 2011, the Centers for Disease Control and Prevention's blog published an article instructing the public on what to do to prepare for a zombie invasion. While the article did not claim that such a scenario was possible, it did use the popular culture appeal as a means of urging citizens to prepare for all potential hazards, such as earthquakes, tornadoes, and floods.^[145]

According to David Daigle, the associate director for Communications, Public Health Preparedness and Response, the idea arose when his team was discussing their upcoming hurricane-information campaign and Daigle mused that "we say pretty much the same things every year, in the same way, and I just wonder how many people are paying attention." A social-media employee mentioned that the subject of zombies had come up a lot on Twitter when she had been tweeting about the Fukushima Daiichi nuclear disaster and radiation. The team realized that a campaign like this would most likely reach a different audience from the one that normally pays attention to hurricane-preparedness warnings and went to work on the zombie campaign, launching it right before hurricane season began. "The whole idea was, if you're prepared for a zombie apocalypse, you're prepared for pretty much anything," said Daigle.^[146]

Once the blog article was posted, the CDC announced an open contest for YouTube submissions of the most creative and effective videos covering preparedness for a zombie apocalypse (or apocalypse of any kind), to be judged by the "CDC Zombie Task Force". Submissions were open until October 11, 2011.^[147] They also released a zombie-themed graphic novella available on their website.^[148] Zombie-themed educational materials for teachers are available on the site.^[149]

CDC Departments

• ATSDR – CDC department
• NIOSH – CDC department
  • N95 respirator – regulated by NIOSH
  • Division of Industrial Hygiene – predecessor to NIOSH

Other US Executive Departments

• MSHA – co-regulator of respirators prior to 1998
  • Bureau of Mines – predecessor to MSHA
• National Highway Traffic Safety Administration
• OSHA